Last month I saw Joan, a woman who has had low back pain for years. She’d been through the ringer like every other person in severe pain: countless procedures and medications. She continued to have daily pain that stopped her from staying focused at work, playing with her kids or being the spouse or friend she wanted to be. After our long consultation and review of her records my prescription was simple – biofeedback, a non-drug treatment in which patients learn to control bodily processes that are normally involuntary, such as muscle tension, blood pressure, or heart rate, and acupuncture to reduce the pain and spasms that were her most recent obstacles.
The response from the insurance company was equally simple: Your requested services are denied as experimental.
As a physician based close to the border in San Diego I have become an unwilling expert on experimental treatments. I have begged patients not to go to Mexico for ozone or non-approved stem cell therapy because it is experimental. In contrast, the treatments we requested for Joan are far from experimental. In fact, both acupuncture and biofeedback were recently recommended as first list treatments by the American College of Physicians (ACP) evidence-based guidelines for chronic low back pain.
What insurers count on are doctors and patients getting tired of fighting the system, a common task that thousands of clinics like ours have to do every day. When the fatigue of appealing for treatments that makes the most sense is beyond what we or the patient can handle, we give up.
These insurance denial letters are simply laughable.
What is not laughable is that Joan’s pain is not going away, and yet we know how to help her. For over 15 years, we’ve been treating patients using a team-based integrative approach that attempts to balance pain treatment by incorporating the best tools, be they medications, procedures, physical therapies or evidence-based non-drug therapies. This approach is clinically effective in reducing pain. Unfortunately, most of this country is not practicing it because of insurance barriers. Even with ACP guidelines, payors continue to routinely deny care using outdated language and are not kept accountable.
As a recent analysis of insurers from around the country published in the Journal of the American Medical Association corroborated, insurers routinely deny many evidence-based non-drug treatments for low back pain such as cognitive behavioral therapy, acupuncture and biofeedback. Our recent analysis accepted for publication with the Center on Health Insurance Reforms at Georgetown University found similarly non-existent coverage for these therapies in state-mandated insurance policies.
However, there are spots of hope: some states are working to get non-drug treatments covered. One pilot in Vermont expanded coverage of previously denied treatments, such as acupuncture, to Medicaid recipients with chronic pain. Researchers found that the program reduced pain and medication use while also improving physical and emotional functioning.
And there is hope at the national level. I recently advised the congressionally-mandated Pain Management Best Practices Inter-Agency Task Force. They recently published draft recommendations providing some of the most meaningful progress to date in creating a balanced approach to pain as well as the education needed to get there. Their plan includes a comprehensive plan for pain care, including access to treatments such as those recommended for Joan.
These draft guidelines are up for comment until April 1 with the final version being presented to Congress later this year. This is the rare opportunity for all Americans to give official input to the Federal Register on how pain care in the US should be transformed.
Good pain care will not come to fruition one appeal letter at a time; and it should not exhaust patients and their clinicians. We have the evidence, we know what works and getting treatment to manage pain should not cause as much suffering as the pain itself.
Robert Bonakdar is a family physician, a director of pain management at a San Diego-based medical facility, and an assistant clinical professor, University of California San Diego School of Medicine. He can reached on Twitter @DrB_Well.
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