Congressional Intent. Alternative Payments. A Plague of Addiction.
In the early 2017 tumult over the fate of the Affordable Care Act and the future of healthcare in America in general, two signal but little-known achievements have emerged that present powerful near-term possibilities for improving healthcare and pain management in particular.
In Oregon, the PacificSource health plan agreed to reimburse a patient under the non-discrimination provisions of the Affordable Care Act: the first time in the existence of the law this has happened.
The Repercussion: Reimbursable delivery of licensed healthcare services and expanded patient access to the integrative healthcare teams of their preference.
In Rhode Island, a three-year Medicaid pilot program provided coordinated integrative health treatments for patients suffering the most complex and costly-to-treat chronic pain conditions. The financial and improved health outcomes: extraordinary.
The Repercussion: CMS coverage for treatment of chronic pain and related complex and costly conditions throughout the Medicaid state network.
Oregon: Reimbursement? The Power of One
Health insurance reimbursement for all licensed U.S. healthcare providers was directed by Section 2706 of the Affordable Care Act: “Non-discrimination in healthcare.” The ACA’s non-discrimination provisions were designed to “correct health insurance marketplace imbalances.” For instance: only a portion of the consumer/patient community can afford to pay out of pocket for many licensed services. State compliance with 2706 would ensure that licensed healthcare providers in every state would be able to deliver reimbursed services. After going into effect Jan. 1, 2014, the provisions have been universally ignored. But now, due to the tenacity of a single Oregon resident, we may see a crack in the historic wall of non-compliance.
For the 2015 birth of her second child, Shannon Sell engaged the services of a licensed certified professional midwife (CPW). Her assumption that midwifery services would be covered by her PacificSource insurance plan turned out not to be so and her claim for coverage was denied. In the course of researching options, she learned about the non-discrimination directives of Section 2706 of the ACA and based her protest on its provisions. Armed with what she assumed was Federal law, she began a lengthy and discouraging 19-month period of claims and communications with both PacificSource and the Oregon Insurance Division (OID), getting nowhere. (Her courageous and compelling — and very telling — story is told here by John Weeks.)
Then, out of the blue, and on the same March day that the U.S. House of Representatives failed to repeal the ACA, Ms. Sell received the surprising word from OID that PacificSource would reimburse those midwifery services after all. The basis for its decision she learned was guidance on Section 2706 from the U.S. Dept. of Health and Human Services, HHS published in May 2015. She did not learn why it took nearly two years to comply, but was happy to read the pertinent language:
“The insurer has agreed that members who go to in-network Licensed Direct Entry Midwives can receive benefits under their policy. They also have agreed that members who seek out-of-network care by a Licensed Direct Entry Midwife would have their benefits paid at the out-of-network level the member policy permits (in a non-discriminatory manner).”
Her assertions about 2706 were confirmed. The PacificSource decision at last covered her birthing services. But its ramifications could be far more extensive. The guidance on Section 2706 by HHS applies to the services of all state-licensed providers. In other words, an out-of-network claim for pain treatment from a state-licensed acupuncturist (historically not covered) should now be subject to the same reimbursement provisions.
Rhode Island: An Alternative Payment Model in Action
The Rhode Island Medicaid pilot – the Integrated Chronic Pain Program model (ICPP, delivered by Advanced Medical Integration Group) [FN-1] — delivered integrative health skills and approaches into a treatment setting where they have demonstrated effectiveness: treating patients who suffer the most complex, debilitating chronic pain and co-morbid conditions. The Rhode Island pilot was designed to address the excessive emergency room visits, over-prescribing of opioid and other prescriptions that characterize the experiences of many Medicaid patients who invariably incur the highest costs in the program. In the “Community of Care” pilot created by the state starting in 2012, patients with this profile were treated with an interdisciplinary care approach coordinated by a holistic nurse case manager and primary case specialists. The team had the latitude to refer to acupuncture, chiropractic and massage therapy among other modalities not normally covered by Medicaid. Results reported in December include:
• Reduced per member per year (PMPY) total average medical costs by 27%
• Decreased the average number of ER visits by 61%
• Lowered the number of average total prescriptions by 63%
• Reduced the average number of opioid scripts by 86%
Ultimately, the report states, “every $1 spent on CAM (complementary and alternative medicine or integrative) services and program fees resulted in $2.41 of medical expense savings.”[FN-2] In a program newsletter from 2015 an account of one patient’s steady improvement over some 18 months reported in a reduction in total monthly treatment costs from $990 to $98.[FN-3]
Alternative Treatment. Alternative Payment.
The extraordinary results of the Rhode Island pilot come at a time when the Centers for Medicare and Medicaid Services, CMS, has been aggressively advancing its program to fund and deploy Alternative Payment Models in a concerted effort to dramatically reduce the costs of U.S. healthcare. Its Quality Payment Program, QPP, is the most far-reaching modification to Medicare and Medicaid since they were established in 1965. It is designed to move healthcare payments away from “fee-for-service” to value: value that is best articulated in the Triple Aim, the foundational care objectives formulated by the Institute for Healthcare Improvement: improving patient health outcomes, satisfaction and reducing the costs of care.[FN-4]
The CMS Innovation Center (CMMI) has funded scores of APMs in recent years aimed at reducing the costs of many recurring treatment scenarios, among them:
• Heart attack avoidance
• Cardiac rehabilitation
• Diabetes prevention
• Joint replacement
• Reducing avoidable hospitalizations
• Strong Start for mothers and newborns
The Rhode Island Medicaid ICPP pilot was not a CMS alternative payment model. But it looks like one. Driven in great part by the discouraging durability of the opioid epidemic and the limitations of pharmacologic pain remedies, this pilot applied expansive care methods, including treatments not normally covered, with interdisciplinary team practice to provide good outcomes, delivering high patient satisfaction and lower costs.
All About Reimbursement
The results shown from Rhode Island (and in a predecessor Medicaid pilot in Florida) are not unfamiliar to integrative and functional medicine clinical teams around the country who treat similar conditions. But whether through direct payment or models like concierge care services that embed non-covered treatments like massage therapy and acupuncture in service fees, the benefits of integrative treatments remain constrained.
It has taken the grueling onslaught of the opioid epidemic and its riptide of heroin addiction to bring integrative therapeutic approaches to the forefront of non-pharmacologic pain management approaches. The lack of reimbursement for these options has arisen right along with the awareness of their value as a serious and limiting factor.
For instance, when the Centers for Disease Control and Health Promotion (CDC) asked in 2015 for comments on its Guidelines for Prescribing Opioids for Chronic Pain, even the most conventional medical organizations were unambiguous. Wrote the American Medical Association:
“…public and private payer policies must be fundamentally altered and aligned to support payment for non-pharmacologic treatments and multimodal care.…”
AMA’s sentiments were shared by the American College of Physicians, the American Pain Society, the American Society of Anesthesiologists and the American Academy of Pain Management among others. But ultimately the CDC guidelines, along with similar recommendations produced in 2016 from the NIH, the White House and CMS did not address the lack of affordable access to non-pharmacologic pain management options. The Medical Board of California wrote:
“…The [draft] guidelines fail to address the fact that many patients do not have access to these modalities, due to lack of insurance coverage or low availability.”[FN-5]
Particularly in terms of the nation’s addiction epidemic, the nation’s most important and influential Federal policy and standards-creating healthcare organizations like the CDC came up well short by not embracing this near universal plea from physician, provider and patient organizations on the issue of reimbursement.
This is why the developments in Oregon and Rhode Island may prove to be so consequential. When viewed together the PacificSource reimbursement decision in Oregon and the Medicaid pilot in Rhode Island reflect true patient-centered forces that are ready to be accelerated. What is more, the legislative, policy and funding instruments are in place to do the accelerating:
- The non-discrimination provisions of Section 2076 still live in the Affordable Care Act (more explicit and emphatic guidelines would not hurt);
- The implementation and results of the Medicaid pilot in Rhode Island clearly mirror what CMS had in mind when it created its transformational Alternative Payment Models program for moving to value-based payment.
Is this truly a Tipping Point for making public and private reimbursement reflect the state of Federal statutes, practitioner license, clear treatment effectiveness and outcomes, cost advantages and patient preferences? At worst, let us hope at least we are beyond the days when a mother of two, infant in arms, will have to raise hell in the state house and in her health plan’s policyholder services department for a year and a half to get somebody to act on two-year old guidance. Thank you, Shannon Sell.
Lastly one has to wonder where pain management would be today if on Jan. 2, 2014, equitably reimbursed non-pharmacologic pain treatment options were in place, well understood and readily available to Americans dealing with pain.
[FN-1] – Provided by Advanced Medicine Integration Group of Chicago under contract to United Healthcare of Rhode Island, the state Medicaid program manager. AMI has been an innovative organizer of bringing integrative clinical services into state and other therapeutic programs.
[FN-2] – John Weeks, “Rhode Island integrative pain Medicaid pilot shows significant savings,” Integrative Practitioner.com Apr. 2017, https://www.integrativepractitioner.com/whats-new/news-and-commentary/rhode-island-integrative-pain-medicaid-pilot-shows-significant-savings/
[FN-3] – “Solving the Pain Problem,” United Healthcare “Community Plan” newsletter. Dec 2015
[FN-4] – About the Triple Aim, at the Institute for Healthcare Improvement. http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx
[FN-5] – John Weeks, “AMA, Other Leading Medical Organizations Urge Insurance for Non-Pharma/Integrative Pain Care,” The Huffington Post, Dec. 17, 2016. http://www.huffingtonpost.com/john-weeks/ama-other-leading-medical_b_13696232.html