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.

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.

Massage therapy and PT

Since well before the Affordable Care Act, massage therapists have been struggling for recognition in the medical community. Alternative care in general suffered from a pretty low opinion, but massage was often lower still. So many insurance policies covered chiropractic and acupuncture treatments without covering massage. Somehow the fact that a massage made you “feel good”, as opposed to having your joints forcibly popped or getting needles stuck into your back, disqualified it from being a part of Serious Medical Care.

And so we fought with insurers and lawmakers about how massage should be treated like the CAM service it already was. The professions already went hand-in-hand, with so many massage therapists working in chiropractic offices, and with LMTs, LAcs, LCs, and NDs so often found under the same roof. Complementary and alternative care in general has such a broad variety of uses, and no single modality should be excluded.

Even though I knew that the changes would not happen immediately, when the Affordable Care Act took effect I assumed that before too long massage would gain its proper place alongside other CAM treatments. Alternative care of all kinds for everyone!

What’s happening with more and more insurance plans, however, is that massage is being thrown in an entirely different category than its CAM brethren. Massage is considered by these insurers to be a type of rehabilitative care, akin to physical therapy.

On the one hand, that’s pretty cool. Physical therapy is undeniably a medical treatment. If massage is like PT, that means massage has earned recognition as a medical treatment. Nice!

On the other hand, being a “rehabilitative therapy” instead of a “CAM therapy” means that massage is not as accessible as its companion modalities. In these insurance plans, chiropractic care and acupuncture treatments are available without needing to meet any deductible first, making them perfect for wellness and preventative care. Massage, however, is trapped behind (sometimes unreachable) deductibles, forcing the client to pay out of pocket for treatment or forego treatment entirely.

I get why they’ve done this, I suppose. The code I use to bill for massage (CPT 97140) is identical to one of the codes that physical therapists use. It’s actually considered a PT code by many insurance companies. And since Section 2706 mandates that insurers cover services based on the type of treatment as opposed to the type of practitioner, this is, in a way, less discriminatory.

But it still leaves me with a very bad taste in my mouth. Because by treating massage therapists in this way, insurers have declared that massage has no place in wellness or preventative care. We shouldn’t be giving massages that feel good (and help prevent future issues); we should only give massages that solve immediate problems.

If that’s the case, then where does rehabilitation end and relaxation begin? What a loaded question.

More and more – and this is true for providers in all physical medicine modalities – I have had to justify to insurers why my treatments are medically necessary. I find myself constantly trying to convince insurance companies that my massages are rehabilitative and purposeful even if the treatment has gone on “too long” (their words) and my client should be completely healed by now.

I was denied coverage for a treatment last week because the insurance company didn’t understand why I haven’t fixed all of my client’s muscle problems completely and forever such that he’ll never be in pain ever again. When I say it like that, it’s easy to see why this is foolish.

You know what should define a medical need? A doctor’s referral. If a doctor writes that his or her client needs massages, those massages are – almost by definition – a medical necessity. And yet, in practice, they don’t make a difference. Somehow insurance companies have convinced themselves (and the public) that they know best, even through they’re driven by profit over anything else.

Going back to my original point, I can’t say that I can see a clear resolution for this mess. The two billing codes* that massage therapists use are considered to be physical therapy codes, and therefore subject to physical therapy reimbursement requirements. It’s not just LMTs – if a chiropractor gives a pre-adjustment massage, this is also treated as rehabilitative treatment. The difference, of course, is that a spinal adjustment is a chiropractic code, and covered like a CAM treatment.

Should CPT 97124 and 97140 be considered the domain of LMTs, and covered in the same way that other CAM care is covered? Or maybe physical therapy should be available without a deductible? Some insurance companies already do that, and I’d be interested to see if it makes a difference in spending. If the insurance companies are all about the money, that might be our only chance of getting the point across.

* Depending on the insurer, sometimes both CPT 97140 and 97124 are considered PT codes, and sometimes only 97140 is. In the latter case, 97124 is either not covered at all or reimbursed at a lower rate.

EHB Discrimination

As I wrote about last week, insurance companies have been doing a great deal of “creative interpretation” in order to make the ACA guarantee only what insurers intend to cover. We see this very clearly with Section 2706: the broad, umbrella coverage of “any health care provider” has been reinterpreted to mean… well, nothing.

In the state of Oregon where I work, I’ve been in contact with the Insurance Division through filing complaints regarding discrimination. It hasn’t been fun.

The process has gone something like this:

  1. I send a list of complaints/denials to the analyst.
  2. The analyst forwards each complaint to the insurance company in question and asks them to explain their actions.
  3. The insurance company replies to the analyst with some reason as to why they denied coverage for this claim.
  4. The analyst forwards the reply to me and tells me that my denial is not, in fact, discrimination under Section 2706.

What’s missing from this chain of events? Something pretty important, actually: Any critical analysis at all of what the insurance companies say. Of course insurance companies are going to defend their actions! It’s the state’s job to tell them when they’re breaking the law. Instead, the excuses are being taken at face value.

After some back-and-forth exchanges, I’ve landed on the overarching reason as to why my massage services keep getting denied: Massage is not considered an Essential Health Benefit.

Way back when Oregon came up with their benchmark plan – that is, a plan that covers all of the Essential Health Benefits outlined in the Affordable Care Act – they did not choose a plan that covered CAM services. Acupuncture, chiropractic, and naturopathic could be added to the plan for an extra fee, but massage was nowhere to be found.

However, just because you say something doesn’t make it true. Massage has been proven to fulfill several of the EHBs in multiple ways. Mental health services. Rehabilitative services. Preventative and wellness services, including chronic disease management. There are documented medical benefits to massage therapy.

But because Oregon decided, however erroneously, that massage therapy did not meet any EHB requirements, LMTs were removed from the (not actually existent) list of “any health care provider” covered by Section 2706.

Most insurance companies aren’t fully denying the service of massage, though. That would effect other provider types who do meet the EHB requirements. Some insurers have placed massage in a category with physical therapy, which means that massage clients need to meet a large deductible before the service is covered, even though other CAM services are available without this hurdle.

Other companies have decided that massage is covered, but only in conjunction with another treatment, such as an chiropractic adjustment or a naturopathic visit. Since LMTs are, by their license, only allowed to perform massage, the only massage therapists who can take advantage of this are those who work under a DC or ND and don’t do their own billing.

…And just like that, we’re back to where we started: CAM coverage for everyone except LMTs. Massage coverage when performed by anyone except an LMT. In what world is a massage necessarily more effective when given by someone who doesn’t have 600+ hours of exclusive training? How can insurance companies claim not to discriminate when they refuse to accept a massage CPT code on its own, but cover the same exact code when it’s coupled with an adjustment or office visit code?

I pointed this out to the analyst, and he just shrugged.

I don’t know if Oregon has drafted a state-specific bill intended to reiterate the aims of Section 2706 (as a few other states have done), but I haven’t heard anything about one. The only reassurance I can find is that the Insurance Division just created a committee to talk about EHB coverage for a new benchmark plan for 2017 and beyond. I wasn’t chosen to be on the committee, but you can bet that I’ll be sharing my opinion.

State Non-Discrimination Laws

There’s a good bit of linguistic gymnastics going on when it comes to interpreting Section 2706:

A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.

What kind of health care provider does Section 2706 apply to? Any kind. By not specifying provider types, the ACA intended to create an all-inclusive umbrella of coverage, so that no provider type would be unintentionally left out. Sounds nice, right? Unfortunately, this non-specific language is allowing insurance companies to continue its discrimination.

That’s what makes the most recent news out of Hawaii so frustrating. Some background: This state is one of a few states (also including New Mexico and Rhode Island) that has been drafting their own version of Section 2706. By making the language of Section 2706 into state law, these states are telling insurance companies that this section of the ACA is important and must be followed.

Last month in Hawaii, the state senate reviewed the language of the bill and decided to rework it to focus support specifically on naturopathic doctors.

Why just naturopaths? Hawaii already has strong insurance coverage for chiropractic and acupuncture; naturopathic medicine needs more protection against discrimination. And so, by specifying that insurance companies cannot discriminate against “naturopathic physicians acting within their scope of practice”, the law gets done what Section 2706 has had trouble doing, albeit for just one provider type. But one provider type is certainly better than none.

Recent news, however, shows just how tight of a grip the insurance companies have on lawmakers. The bill that had been reformulated to protect naturopaths has been amended yet again back to its original focus, the more general protection of “all licensed care providers”.

And, sure, that might sound great – everyone gets covered, right? Not just naturopaths, but also massage therapists. A win for us, surely?

But protection for “any health care provider” is already the exact language of Section 2706, and insurance companies are fighting hand-over-fist to allow continued discrimination. And considering that this change was in part due to requests by Kaiser Permanente, I think the insurance companies know exactly what they’re doing.

Cover My Care’s Toolkit

Cover My Care – the new outreach program for IHPC – has recently released their 2706 Toolkit.

From the CMC Toolkit page:

Our 2706 Toolkit provides information and tools for anyone interested in advancing the purpose of Section 2706: educating officials in your states, insurance company management, the local media, and joining or forming groups of consumers, patients and providers who insist that full access to affordable licensed providers is important to health care choices now and for the future.

Whether you’re a CAM practitioner or a patient who utilizes integrative medicine, the Toolkit has plenty of material for you to share with friends and clients.

Stay tuned! Coming soon to CMC: A page where you can share your stories of insurance denial and read what other patients have been going through.