How Health Insurers Hurt People in Pain, Part I: Benefit Restrictions
How Health Insurers Hurt People in Pain
Part I: Benefit Restrictions
Approximately 50 million U.S. adults* experience chronic pain, and roughly 20 million of these—over 35% of people who have chronic pain—report being severely debilitated by pain (Zelaya et al. 2020). Physician and government agencies agree that pharmacological alternatives to opioids and non-pharmacological pain interventions are crucial to effective chronic pain relief (Department of Health and Human Services 2019). Yet in the U.S. chronic pain endurers face dire health insurance barriers to treatment.
Central to this problem of ineffective pain treatment is the lack of a universal or binding requirement as to what treatments insurers must cover. Under the Affordable Care and Patient Protection Act (ACA), also referred to as “Obamacare,” almost all private individual and small business insurance plans must cover certain essential health benefits. But what is included in these benefits varies by state and insurance plan. For instance, medication prescriptions and rehabilitation are required, but which medications, the number of rehabilitation visits, and out-of-pocket costs differ by plan.
A review examining the 2017 essential health benefits benchmark plans in all states and the District of Columbia found that numerous evidence-based chronic pain interventions for chronic low-back pain, like acupuncture and Mindfulness-Based Stress Reduction, were rarely or never included (Bonakdar, Palanker, and Sweeney 2019). Many treatments were specifically excluded from coverage as “complementary and alternative medicine.” Additionally, effective 2020 state benchmark options were also relaxed, which means ACA plans may cover even less chronic pain treatments (Centers for Medicare and Medicaid Services 2019).
Under Medicaid, what is included in essential health benefits coverage depends on the state (Heyward et al. 2018). Requiring a very specific diagnosis to receive certain treatments, strict prior authorization rules, and limits on number of visits greatly contribute to the variance and restriction in what is offered by state. In many cases, coverage information is not made readily available (American Occupational Therapy Association 2020).
Original Medicare, a federal program for seniors and disabled people receiving Social Security Disability Insurance (SSDI), has standardized pain management coverage. However, one-third of all Medicare beneficiaries opt-in to Medicare Advantage plans, which are commercial plans that may be selected in place of Original Medicare (Jacobsen, Damico, and Neuman 2019). Like Medicaid and private insurance, the extent that chronic pain treatment is covered in Advantage Plans is highly variable and can differ by state.
Even if an insurance plan covers a particular chronic pain intervention it does not necessarily mean it will be accessible to a particular patient. As mentioned, narrow diagnosis requirements, availability of the treatment, prohibitive co-pay or other costs, inadequate physician treatment education (Heyward et al. 2018), and lack of transportation are all frequent barriers to accessing chronic pain care (Department of Health and Human Services 2019). Race, class, and gender prejudices are also well documented as widespread barriers to comprehensive pain treatment.
This maze of confusion is a microcosm of much broader political and economic barriers to effective chronic pain care and treatment. There are multiple factors contributing to the inadequacy of public and private health insurance in effectively addressing chronic pain. Read How Health Insurers Hurt People in Pain Part II: Financial Gain Over Patient Wellbeing for more about tactics insurers use to block pain treatment.
Chronic pain treatment and research recommendations over the last decade:
2011: The Institute of Medicine (now the National Academy of Medicine) published Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.
2014: American Academy of Pain Medicine (AAPM) released recommendations, “Minimum Insurance Benefits for Patients with Chronic Pain,” advocating for multidisciplinary options for chronic pain.
2016: Department of Health and Human Services (HHS) released the “National Pain Strategy” to implement Relieving Pain in America recommendations.
2017: American College of Physicians (ACP) published guidelines for treating low back pain.
2019: Department of Health and Human Services (HHS) Inter-Agency Pain Research Coordinating Committee (IPRCC) published, “Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations”.
2020: ACP published guidelines for treating non-low back pain.
*Not including people who are incarcerated or otherwise institutionalized, which makes this number much higher in actuality.
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Sources
American Occupational Therapy Association. “An Analysis of the 2019 Rehabilitation and Habilitation in Qualified Health Plans.” aota.org. Stateside Associates. Accessed April 1, 2021. https://www.aota.org/Advocacy-Policy/Health-Care-Reform/News/2020/Analysis-2019-Rehabilitation-Habilitation-Qualified-Health-Plans.aspx.
Bonakdar, Robert, Dania Palanker, and Megan M Sweeney. “Analysis of State Insurance Coverage for Nonpharmacologic Treatment of Low Back Pain as Recommended by the American College of Physicians Guidelines.” Global advances in health and medicine. SAGE Publications, July 29, 2019.
Centers for Medicare and Medicaid Services. “Information on Essential Health Benefits (EHB) Benchmark Plans.” Accessed April 2, 2021. https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.
Department of Health and Human Services, and Assistant Secretary for Health (ASH). “Pain Management Best Practices Inter-Agency Task Force.” HHS.gov. US Department of Health and Human Services, August 26, 2019. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf.
“Essential Health Benefits - HealthCare.gov Glossary.” HealthCare.gov. Accessed April 3, 2021. https://www.healthcare.gov/glossary/essential-health-benefits/.
Heyward, James MPH. “US Insurer Coverage of Nonpharmacologic Treatments for Low Back Pain.” JAMA Network Open. JAMA Network, October 5, 2018. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2705853.
Jacobson, Gretchen, Anthony Damico, and Tricia Neuman. “A Dozen Facts About Medicare Advantage in 2019.” Edited by Meredith Freed. KFF, August 6, 2019. https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage-in-2019/.
“Pain Management.” Medicare.gov the official US Government site for Medicare. Accessed April 1, 2021. https://www.medicare.gov/coverage/pain-management.
Zelaya, Carla E., James M. Dahlhamer, Jacqueline W. Lucas, and Eric M. Connor. “Chronic Pain and High-Impact Chronic Pain Among U.S. Adults, 2019.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention NCHS Data Brief No. 390, November 4, 2020. https://www.cdc.gov/nchs/products/databriefs/db390.htm.
