Beginning July 1, 2016, Oregon Medicaid patients with spinal pain (cervical, thoracic, lumbar, pelvic) who are determined to be low risk based on a biopsychosocial assessment tool (STarT Back – Keele University) can receive four chiropractic visits per episode.
Patients who score high risk on a biopsychosocial assessment tool (e.g., pain catastrophizing, fear avoidance) can receive up to 30 chiropractic visits, but in an aggressive integrated clinical approach. This integrated approach includes cognitive behavioral therapy re-evaluated every 90 days.
Coverage for this therapy will only be continued if there is documented evidence of decreasing depression or anxiety symptomatology, improved ability to work / function, increased self-efficacy, or other clinically significant objective improvement. Chiropractic treatment of high-risk patients will continue to be covered only when there is documentation of measurable clinically significant progress toward the therapy plan-of-care goals and objectives using evidence-based objective tools (e.g., Oswestry, Neck Disability Index, SF-MPQ and MSPQ).
Background
The Oregon Health Authority (OHA) announced on May 2, 2016 that delayed changes to Oregon's "Prioritized List" involving nonpharmacological treatments, such as chiropractic spinal manipulation, for conditions of the back and spine will be implemented on July 1, 2016. The implementation of these changes had been delayed from their original planned date of Jan. 1, 2016.
In 1989, Oregon legislation established the Oregon Health Plan, which called for the expansion of Oregon's Medicaid program to individuals and families up to 100 percent of the federal poverty level. This legislation also directed the development and use of a prioritized list of health services to determine the benefits available to Oregon's Medicaid clients. However, the typical diagnoses used by doctors of chiropractic relative to uncomplicated back or spinal pain – and our typical treatments – fell below the funding line of Oregon's prioritized list and were not covered.
In 2012, the Health Evidence Review Commission was created, consisting of 13 governor-appointed and state Senate-confirmed volunteer members. Members of the commission include five medical physicians, one osteopathic physician, a dentist, a public health nurse, a behavioral health representative, provider of complementary and alternative medicine (chiropractic, naturopathic physician or licensed acupuncturist), a retail pharmacist and two consumer representatives.
The Bigger Picture
The methodology used to prioritize health services, which other states may wish to duplicate, places a high emphasis on preventive services and chronic disease management; and the recognition that the utilization of these services can lead to reduction in more expensive and often less effective treatments provided in the crisis stages of disease. The ranking of health services reflects the best unbiased information on clinical effectiveness and cost-effectiveness available; and the values of the state's citizens.
In the United States, back conditions are common within the Medicaid population, as is substance abuse and the overuse of opioid narcotics. The Centers for Disease Control and Prevention (CDC) estimates 44 people die every day from overdosing on prescription pain medications, with many more becoming addicted.
Since 1999, the amount of pain medications prescribed and sold in the nation has quadrupled, with 259 million prescriptions for opioid narcotics being prescribed in 2012. Although many episodes of acute spinal pain are self-limiting one-third of patients report persistent back pain of at least moderate intensity one year after an acute episode.
Many studies including four meta-analyses confirm that opioids and benzodiazepines should not be recommended as second-line therapy for chronic low back pain. During the early 1990s, a RAND Corporation study was included in the landmark Agency for Health Care Policy and Research back pain guidelines of 1994 and noted chiropractic spinal manipulation not only relieved pain, but more importantly, restored spinal joint function, something harmful medications cannot duplicate.
Based on the existing global literature, the official Oregon Evidence-Based Low Back Pain Management Guidelines (2012) recommended spinal manipulation as the only nondrug intervention for all three phases of low back pain: acute, subacute and chronic. Combined with the growing prescription opioid narcotic problem, this placed pressure on state officials to look at changing health care policy in regards to the Medicaid population, who did not have access to the various nonpharmacological interventions the state of Oregon recommended.
What Can You Do?
My take-home message is simple: You and other chiropractic physicians in your state must become involved in your state's policymaking advisory committees, commissions, task forces, work groups and boards. At each step of the way, representing the Oregon Chiropractic Association, I have been involved in all key policymaking groups that led to this new Medicaid policy, which will now cover chiropractic services with parity. I began by assisting in the development of the low back pain guidelines for our state, and have served four years on the new Health Evidence Review Commission (HERC) and the HERC's Subcommittee on Evidence-based Guidelines and Coverage Guidance, which developed and approved the guidelines. I then served on the HERC's task force to reorganize the prioritized list guidelines dealing with back and spinal pain.
In my opinion – as I have stated before in this column – your state association cannot depend on lay lobbyists to perform this work; they simply will not commit the time necessary to attend literally hundreds of hours of policy work, nor do they have the clinical expertise to even do so.
Editor's Note: Click here to review a fact sheet regarding the policy changes relative to the treatment of back conditions within the Oregon Medicaid system.
Click here for more information about Vern Saboe Jr., DC, DACAN, FICC, DABFP.