The National Governors Association (NGA) recently released a 24-page report, "Expanding Access to Non-Opioid Management of Chronic Pain: Considerations for Governors," recommending an integrative approach to pain, including acupuncture. The implications for our profession are far-reaching.
The NGA recognized the biological, social and psychological drivers of pain (AKA, biopsychosocial aspects) that require "expanding access to therapies such as physical and occupational therapy, behavioral health interventions or integrative and complementary approaches to manage common musculoskeletal conditions, such as low back pain, alongside prescription opioids."
Addressing the "Pain-demic"
The report (thankfully) points out that little evidence exists to support the long-term use of opioids for non-cancer-related chronic pain; and refers to CDC statistics of nearly 71,000 Americans dying of drug-related overdoses in 2019, which was an increase of 4.6 percent compared to the previous year.
Eric Hargan, deputy secretary of Health and Human Services, announced in late 2017 that the opioid crisis was a public health emergency in our nation (where patients received more than 191 million opioid prescriptions that year). That is, until it got eclipsed by the COVID-19 pandemic.
Since February 2020, there has been a "pain-demic" brewing in the U.S. and affecting 100 million Americans, and the NGA report authors emphasize there are non-opioid therapies available that are safe and effective.
The NGA brought together a round table of experts to explore innovative, coordinated, interdisciplinary care delivery models, including Bob Twillman, PhD, former executive director of the Academy of Integrative Pain Management (AIPM) and current director of the Integrative Health Policy Consortium (IHPC). The pain management specialists suggested the best approach includes patient education on how to improve their physical function, address stress and trauma that may lie at the root of their pain experience, and access services to provide pain relief. The report recommends "coordinated, interdisciplinary care" because it is considered the gold standard in health care delivery and provides a solid return on investment.
A Lack of Policy Implementation?
The National Governors Association also strongly recommended coverage through Medicaid to meet the increasing demand for nonpharmacologic approaches to pain management, specifically listing acupuncture, restorative movement therapies such as physical and occupational therapy, behavioral health interventions, tai chi and yoga. They referred to a 2016 National Academy for State Health Policy survey of Medicaid agencies which found that while most states had taken action to limit inappropriate opioid prescribing, only 12 of 41 responding states indicated that they had implemented programs or policies to encourage or require the use of non-opioid pain management therapies.
A Rhode Island pilot study through Medicaid using acupuncture and manual therapies (an integrated pain program) reduced the average number of ER visits by 61 percent, reduced the average number of opioid prescriptions by 86 percent (and total number of prescriptions by 63 percent), and reduced overall annual medical costs by 27 percent. Every $1 spent on CAM services and program fees resulted in $2.41 of medical expense savings.
These are strong numbers, and one of the reasons CMS made the move for Medicare to cover acupuncture for low back pain (beyond pouring through stacks of randomized, controlled trials).
When interviewing states about systemic challenges associated with implementing non-opioid and nonpharmacologic pain management policies or programs, the NGA authors mentioned three key issues:
- Lack of ongoing provider education. Primary care providers do not receive extensive training in pain management and often feel overwhelmed by the complexity of chronic pain cases; or do not have the information they need to make an informed referral to practitioners of nonpharmacologic approaches.
- Shortage of skilled workers. Behavioral health care providers are often in short supply and may not be trained in chronic pain management strategies.
- Substantial geographic variation. Access to behavioral health providers, acupuncturists and chiropractors differs significantly based on locality.
Trends to Track
The report specifically refers to Ohio expanding access to nonpharmacologic therapies through state plan amendments (SPAs) under what's known as the "other licensed practitioner services" benefit to reimburse acupuncturists for covered services. (Originally, only "qualified" chiropractors were reimbursed for acupuncture services in Ohio, but the services are now covered when performed by licensed acupuncturists.)
Since 81 percent of Medicaid beneficiaries are enrolled in some type of managed care, the NGA recommends states with managed care consider partnering with their managed care organizations to expand access to non-opioid pain management services for those patient populations.
At least three states (California, Oregon and Rhode Island) have included pain management initiatives in their broader section 115 Medicaid demonstrations, which allows states the flexibility to test new approaches that would otherwise not be permitted under federal rules. In Oregon, for example, coordinated care organizations are expected to participate in a statewide performance improvement project to reduce chronic opioid use and promote evidence-based, non-opioid therapies like acupuncture, yoga, chiropractic, cognitive behavioral therapy and interdisciplinary rehabilitation.
The report also promotes telehealth to improve access in rural communities, and provides state leaders the tools they need to implement strategies that help chronic pain patients regain function, manage pain and improve quality of life.
Not If, But When
It's not "if," but "when" acupuncture services are covered by both Medicare and Medicaid, and the question remains about the reimbursement rates. Efforts are underway toward licensed acupuncturists being included as a "provider type" in CMS legislation, which will remove the need for a physician "supervisor" or intermediary for payment.
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