Though the increased focus on pain treatment resulted in increases in opioid prescriptions in most doctors initially, for years now, pain specialists have advocated using alternative treatments [referring to interventional procedures, like epidurals] to alleviate their patients’ chronic pain.
There’s one problem:
Health-insurance companies are increasingly cutting reimbursements for these alternative treatments or not covering them at all.
This is partly because they haven’t been proven to be very effective.
Here are just a few of the treatments advocated by pain specialists in place of opioids:
- Steroid injections,
- joint injections,
- fluid injections, [prolotherapy]
- physical therapy, [the only non-invasive Tx mentioned]
- nerve blocks, and
- radio-frequency ablation
Such treatments are frequently called interventional pain treatments.
These physically invasive treatments often leave patients with worse pain than before. A few, very few, are helped by them and even then, the pain usually returns so the treatments must be repeated for the rest of life.
The doctors that specialize in these hazardous surgeries and procedures are members of the Society of Interventional Pain Physicians.
When opioids are no longer accessible to pain patients, more of them will be coerced to undergo these expensive (and lucrative) procedures.
Patients have so few options and these treatments are covered by insurance (but not the alternative treatments that the CDC recommends).
The self-interest of interventional pain specialists dictates their position against opioids, which are used by patients to avoid these mostly ineffective procedures. (See tag “surgery” for more posts about this)
Several years ago, these interventional pain specialists joined forces with addiction recovery program executives to form the virulent anti-opioid “under any circumstances whatsoever” group, Physicians for Responsible Opioid Prescribing (PROP).
Without opioids, pain patients are left with very few, very poor options:
- Try mostly ineffective “alternative” medicine treatments (insurance doesn’t pay)
- Try psychotherapy like ACT Therapy (insurance doesn’t pay for continuous weekly sessions)
- Try risky surgical procedures sold by interventional pain specialists (insurance pays for initial surgery)
“Every year, pain interventions go to the chopping block, and doctors have to figure out how to provide that treatment and make ends meet,” Dr. Janet Pearl, the medical director of Massachusetts-based pain-management center Complete Pain Care and the secretary of the Massachusetts Society of Interventional Pain Physicians, told Business Insider.
The policies of insurance companies have forced doctors to increasingly offer pain patients a difficult choice, according to Dr. Shalini Shah, the director of pediatric-pain management at UC Irvine Health.
- Pay for expensive alternative treatments out-of-pocket,
- use opioids and possibly suffer a myriad of side effects and risk opioid addiction, or [no longer possible in most cases]
- choose to do nothing and live with debilitating pain.
In some cases, insurance companies have classified widely accepted procedures in recent years as “experimental” or “investigational,” therefore making them ineligible for reimbursement, despite decades of common use.
Pain physicians brought up one such procedure again and again in conversations with Business Insider: radio-frequency ablation. First used in 1931, the procedure entails a physician using electric currents to decrease pain signals from the specific nerve causing a patient pain.
Radio-frequency ablation has been “well described in literature, scientifically studied extensively, and used to be covered,” Shah said. “Now insurance companies are saying ablation is experimental.”
There are currently five randomized trials using radio-frequency ablation for lower-back pain, the most common ailment treated by pain physicians. Three studies found positive results, one negative, and one ambiguous, leading an expert review in Medscape to conclude that the procedure is effective, given “careful patient selection.”
United Healthcare; Anthemand various other Blue Cross Blue Shield-affiliated health-insurance companies; Aetna; and various Medicare-contracted payers have deemed the usage of radio-frequency ablation specifically for the sacroiliac joint to be “experimental” or “investigational.”
This despite at least nine studies each showing significant levels of pain relief after using radio-frequency ablation for the sacroiliac joint.
As with all pain treatments, these can be very effective for some patients and not at all for others.
Remember, a statistical average of being effective for 50% of patients can – and often does – mean that 50% of patients had zero response and the other half had a spectacular response.
Averages are not terribly useful in medicine.
This situation is not unusual, according to Pearl, who says that insurance companies have cut back on or cut completely previously accepted procedures under the rationale that doctors or researchers haven’t proven their “efficacy.”
With negative studies no longer published, they manage to avoid any discussion of the horrible damage done to a significant number of patients, leaving them in worse pain.
In the January 2014 issue of Pain Physician, the official publication of the American Society of Interventional Pain Physicians (ASIPP),a cadre of pain specialists lamented the “draconian cuts” to numerous interventional pain treatments by commercial insurers and Medicare in a piece titled “Declining Value of Work of Interventional Pain Physicians.”
This is due to simple greed.
As opioids are being banned, more patients are now coerced into dangerous interventional procedures and this market is expected to grow by leaps and bounds.
So many new Pain Management Clinics have popped up in every strip mall that the market is now oversaturated.
Their proposed solution?
Whine that they’re not being paid enough by insurance companies.
Later that year, a similar group of pain specialists published an update to the cuts, noting that interventional pain physicians are struggling to keep their practices open and survive into the future because of “increased regulations,” expenses, and other issues.
Shah was unequivocal when asked why she thinks non-opioid pain treatments have been restricted.
“Simple. They cost more. It costs more for insurance companies for a physician to do a procedure on a patient or to do physical therapy. It is far cheaper for us to write a prescription for a 30-day supply of morphine.
That’s the only reason,” Shah explained.
He’s very wrong about that. The other, and probably more pertinent, reason is that they are risky and not very effective.
Because insurers have a “fiduciary responsibly” to their millions of subscribers, insurers will frequently weigh a treatment’s cost into their coverage decisions, even if the treatments are medically efficacious
Where that “value-based” decision-making runs into trouble is when insurers’ policies push patients toward dangerous or potentially addictive medications in lieu of equally effective medications that aren’t dangerous.
Part of the problem, says Dr. Neel Mehta, the medical director of pain management at New York-Presbyterian and Weill Cornell Medical College, is that in many cases, the pain cannot be completely eliminated, only managed.
Alternative treatments advocated by most pain physicians are not typically “one-and-done” procedures, but instead may need to be done periodically to treat the pain.
Because of that, insurance companies may be making an unpopular but, in their minds, necessary judgment: If patients would have to undergo these treatments indefinitely, they may as well go on opioids, the lowest-cost option.
Opioids however, may only appear cost-effective in the short term.
“That’s the fallacy. If you look at the long-term cost of [opioids], plus monitoring, office visits and drug screenings … it’s cheaper long-term to do the more advanced therapy,”
The problem with pain medicine
Health insurers base their coverage decisions on the available medical evidence around safety and effectiveness, according to Krusing.
This evidence includes guidelines and recommendations from medical societies as well as peer-reviewed studies in the field.
When doctors or hospital systems ask for a treatment to be covered, insurers will have their medical staffs evaluate that procedure based on the evidence.
The system seems sensible enough, but the field of chronic pain is ill-suited to such an approach for a number of reasons, according to pain specialists.
The first is that pain is inherently subjective, which makes measuring it (and the effect that a particular treatment might have) a difficult task, according to Danesh.
Many insurance companies have policies that say doctors providing patients with pain injections must show that a patient experienced 50% to 80% pain relief before doing the treatment again, he added.
Another issue is that there are a limited number of high-quality clinical studies for pain treatments. While this is partially because pain treatment is a relatively young medical discipline, the bigger issue is that pain studies are fundamentally difficult to recruit for, according to Mehta.
Asking patients in debilitating pain to risk receiving a placebo and waiting months to measure the treatment (or the placebo’s) effect is a big ask, according to Mehta, who says many patients opt to skip participating in clinical trials in favor of taking opioids or, if they have the means, paying out of pocket.
‘Broadening’ the treatment options
In theory, competition among insurers should fix the coverage problem, according to Schweitzer.
This scenario assumes that consumers are informed and in control of their policy decisions and that some insurers are substantially better than others about covering the treatments.
This doesn’t appear to be the case, pain specialists told Business Insider.
They maintained that while insurers may vary about which specific treatments they cover, they’re all cutting back on coverage and reimbursements for alternative pain treatments as a whole.
The issue hasn’t been limited to commercial-healthcare companies either. Coverage decisions and recommendations made by the government tend to have ripple effects across the industry, according to Schweitzer, with many insurers looking to the government for indications on what to cover.
Guidelines and coverage recommendations released by the Centers for Disease Control And Prevention (CDC) and CMS have received significant pushback from pain specialists in recent years.
In a joint letter to the CDC in January, the American Society of Anesthesiologists (ASA) and the American Society of Regional Anesthesia and Pain Medicine (ASRA) raised several issues with the CDC’s proposed guidelines for prescribing opioids.
The letter notes that many of the guidelines’ recommendations, specifically about encouraging non-opioid approaches, are difficult to implement because many of those approaches are not covered by insurance.
In addition, the letter took the CDC to task for what appears to be improperly characterizing treatments, including epidural steroid injections, radio-frequency ablation, and spinal-cord stimulation — three core non-opioid pain treatments — as being “associated with rare, but serious adverse events” and being linked to only “short term” benefits.
Yet, this is exactly what the evidence shows.
They cannot say, “we don’t give opioids because there is no “scientific evidence” they are effective” and then turn around and argue against “scientific evidence” when it’s opposed to their own financial interests.