Tuesday, February 7, 2017

Body TruthWhen the Affordable Care Act (ACA) passed in 2010 it contained provisions long sought by the nation's several hundred thousand licensed integrative health care providers who had rarely, but mostly never, been included in health insurance reimbursement. Section 2706, "Non-discrimination in healthcare," went into effect January 1, 2014 and directed state health insurance regulators to ensure that licensed providers of acupuncture, massage therapy, chiropractic, naturopathic medicine, and other disciplines were included in provider networks.

In January, Section 2706 passed its third anniversary in disappointing fashion: it ended the third year during which no single state's insurance regulator had issued rules or otherwise directed its health insurance companies to comply with non-discrimination provisions. Even though this section of the ACA is unlikely to draw much attention in any repeal-and-replace efforts (it involves no funding and contains no enforcement provisions, and was heartily ignored in any case), it is likely to have a lasting impact irrespective of the fate of the ACA. The emphasis on non-discrimination will continue to advance and be reinforced by factors that have been driving adoption of integrative practice since long before the ACA went into effect:

  • Section 2706 has spurred a small but influential network of advocacy coalitions in the states that continue to work to end insurer discrimination where it really matters: in their home markets, through legislation and educating regulators, employers, and payers.
  • Potential involvement in these coalitions by hospital systems, medical schools and primary care clinics that now include integrative modalities in their treatment plans even though they still remain unreimbursed.
  • The outcomes of state Medicaid programs and pilots organized to treat patients with the most difficult and complex and costly conditions, notably for pain management. In no small part these respond to the crushing impact of the opioid epidemic on state treasuries.  Last December the results of a three-year Rhode Island pilot showed significant clinical success, reduced utilization, and cost reductions.[1] 
  • The move toward value payment models being pushed by the Centers for Medicare & Medicaid Services (CMS) through its Quality Payment Program. As the Medicaid pilots suggest, and as the licensed practitioners have asserted for years, integrative approaches to care are very well suited to addressing the often complex conditions of chronic ill health, addiction, and pain experienced by many Medicare and Medicaid beneficiaries.

It all ends up in the states

This spring, coalitions of providers in Minnesota and New Mexico will introduce bills informed by Section 2706's non-discrimination provisions that also address related patient and insureds' concerns. The bill written by the Minnesota Fair Care (MN Fair Care) coalition, for instance, would give patients the freedom to spend their deductible dollars with any licensed provider they choose, rather than sticking with those in their plan's network.[2] In New Mexico, a coalition of providers and the state superintendent of insurance met during the summer, but could not find a way to bring about 2706 compliance by rule, so new legislation has been prepared.

In Nevada, the state division of insurance held a public meeting in January seeking guidance on how to implement the provisions of a statute that ensures that chiropractors are reimbursed at an equivalent rate for identical treatments with MDs and DOs. This statute was passed in 1981, and was only recently rediscovered by the agency. In early January, Massachusetts became the 22nd U.S. state/territory to license naturopathic doctors (NDs). That followed Pennsylvania's November action to regulate its NDs. Naturopathic doctors are particularly capable through their formal medical education to offer the kind of lifestyle-based interventions that many care systems now recognize as very effective approaches for treating the most difficult and costly conditions of illness.

Waiting on coverage for integrative pain management

The intention of a fully realized 2706 was to correct imbalances in the health insurance marketplace and match massive public use of safe and effective care options with their insurance plans. Those imbalances remain, but in the case of pain management at least, the detrimental effects of their limitations are becoming clear. In early 2016, the Centers for Disease Control and Prevention (CDC) opened a public comment period on its draft Guidelines for Prescribing Opioids for Chronic Pain. Among the primary themes of the responses, the lack of reimbursement stood out as a primary hurdle to expanding effective options. This was notably expressed by the American Medical Association (AMA), which wrote in its response:

“Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Providers should only consider using opioid therapy if expected benefits for pain and/or function are anticipated to outweigh risks. In order to achieve this goal, public and private payer policies must be fundamentally altered and aligned to support payment for non-pharmacologic treatments and multimodal care.”[3]

Similar comments noting the need for reimbursement were expressed by the American Society of Anesthesiologists (ASA), the American Pain Society (APS), the Medical Board of California (MBC), the American College of Physicians (ACP), and the Trust for America’s Health (TFAH).  

Section 2706 may well fade away with repeal of the ACA, but its promise and potential—and the forces behind them: patient preferences and clinical efficacy—remain potent and are driving actions in the states. For certain, costly chronic illness and pain are not going away. And the opioid epidemic will not subside without concerted efforts to establish a new therapeutic order for pain management, moving the least invasive, non-addictive options to the head of the treatment line when that is appropriate.[4] 

Related:  More on Medicaid pilots and state programs from October 2016: http://altarum.org/health-policy-blog/confluence-in-waiting-cms-alternative-payment-models-and-integrative-healthcare


[1] - The costs to treat a patient with multiple chronic conditions fell from more than $900 a month to $90 a month after 18 months of nurse case managed treatment.  (Reported in United Healthcare RI "Community Plan" newsletter, December 2015. http://www.integrativestrategies.us/?page_id=1317

[2] - Minnesota Fair Care members include professional organizations representing chiropractors, optometrists, naturopathic physicians, podiatrists, massage therapists, athletic trainers, PhRMA's state chapter, and national pain management and integrative health policy organizations.

[3] - For a summary of 2016 comments to the CDC on its guidelines for opioid prescribing by the AMA and others, see: http://www.huffingtonpost.com/john-weeks/ama-other-leading-medical_b_136...

[4] - It is worth noting that the well-known American Academy of Pain Management, AAPM, changed its name last year, to become the Academy of Integrative Pain Management. 


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