Coverage of Nonpharmacologic Treatments for Low Back Pain Among US Public and Private Insurers

Key Points Question Among US insurers, what are the coverage and utilization management policies for nonpharmacologic treatments for chronic, noncancer low back pain? Findings In this cross-sectional study of 45 Medicaid, commercial, and Medicare Advantage plans, most plans covered at least physical and occupational therapy and chiropractic care for chronic noncancer pain, but there was little evidence of coverage of acupuncture and psychological interventions. Utilization management strategies such as visit limits and prior authorization were common, but criteria varied widely across the plans examined. Meaning The lack of consistent coverage and utilization management policies underscores the need for best practices to improve comprehensive, multimodal coverage of treatments for chronic, noncancer low back pain.


eAPPENDIX. SELECTION OF PLANS. 27
Selection of Medicaid Plans 28 We selected 16 states based on varying demographics, such as large and small populations, 29 wealth, level of urbanicity, and those with disproportionately high rates of injuries and deaths 30 from prescription and non-prescription opioids, such as Ohio, West Virginia and Maine. 1 Within 31 tertiles of FMAP scores, we selected 4-6 states with varying population sizes and geographic 32 regions, as defined by the United States Census Bureau. As a result, we selected 1 to 2 states 33 from each of the 9 geographic regions. Using data from the Kaiser Family Foundation, 2 we 34 selected Medicaid formularies from the largest Managed Care Organization (MCO) in each 35 state, with the exception of one state's largest MCO, whose publicly available formulary listed 36 analgesics in a unique fashion. We instead used the formulary from the second largest 37 Medicaid MCO in this state.

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Selection of Medicare Advantage Plans 40 Since their inception, the proportion of Medicare beneficiaries enrolled in Medicare Advantage 41 ("Part C") has steadily grown, relative to traditional ("fee-for-service") Medicare. 3 In 2017, 42 Medicare Advantage enrollees numbered 19.0 million and accounted for 33% of all Medicare 43 beneficiaries. To maximize representativeness, we selected the same 15 states as for the 44 Medicaid plans, with the exception of Vermont, where we substituted Connecticut, due to 45 Medicare enrollment data availability. Connecticut also has a relatively small population and is 46 located in the same geographic region as Vermont. Our overall selection of states for Medicare 47 Advantage also varied greatly in the number of their Medicare Advantage beneficiaries.

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We referred to enrollment data from Medicare.gov to select Medicare Advantage Plan Types, 50 such as health maintenance organization (HMO) or preferred provider organization (PPO) 51 plans, with the largest or second largest enrollment in each state. Meanwhile, we ensured 52 selection of plans from the largest 5 Medicare Advantage insurers, including Aetna, Anthem, 53 Humana, Kaiser Foundation and United Healthcare, as well as a variety of smaller payers. We 54 then selected plans with a variety of star ratings, which are offered for reference by 55 medicare.gov. Star ratings are an evaluation of a plan's overall quality and performance, 56 determined by the Centers for Medicare and Medicaid Services, while taking member 57 experience into consideration.

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Selection of Commercial Plans 60 We selected 15 plans derived from a total of 7 states, in order to examine multiple plans within 61 the same state. These 7 states were of different population sizes and geographic regions, 62 selected from the list of states for the Medicaid plans. These states also varied in the 63 magnitude by which they were affected by the opioid epidemic. We examined three commercial 64 plans from each of 2 states, two commercial plans from each of 4 states, and one commercial 65 plan from the last state.

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Recent estimates suggest 74.9 million Americans are covered under private insurance. 4

eTABLE 3. DIFFERENTIAL INCORPORATION OF UTILIZATION MANAGEMENT STRATEGIES ACROSS 45 MEDICAID, MEDICARE ADVANTAGE AND COMMERCIAL PLANS FOR SELECT COVERED NON-PHARMACOLOGIC TREATMENTS
Physical Therapy Chiropractic Care Acupuncture Condition requirements: • Medically determinable functional physical impairment, weakness, atrophy, and/or a decreased range of motion • Loss of function due to illness, injury, loss of a body part, or congenital abnormality