The objective of this study was to understand the experiences of nonpharmacologic therapy (NPT) providers implementing the Oregon Back Pain Policy (OBPP). The Medicaid OBPP expanded coverage of evidence-based NPTs for back pain and simultaneously restricted access to acute and chronic opioid therapy and some interventional approaches for chronic back pain.
Materials and Methods:
This study uses a cross-sectional, observational design. The authors conducted three online focus groups with 44 credentialed NPT providers in February 2020. Qualitative data analysis was conducted by a multidisciplinary team with an immersion/crystallization approach.
Results:
Four themes emerged from the data. Participants reported: (1) a lack of direct communication about the policy and mixed levels of understanding of the policy, (2) belief that expanding access to NPT and restricting opioids was beneficial for patients, (3) implementation challenges that compromised access and the perceived effectiveness of care, and (4) financial challenges in accepting Medicaid referrals, due to reimbursement and administrative burden.
Conclusion:
The goal of the OBPP was to increase access to evidence-based back pain care, including new coverage of NPT services and decreased opioid prescribing for back pain. This study revealed that although many NPT providers support the goals of this policy, the policy was not communicated systematically to providers and was hampered by implementation challenges.
Get full access to this article
View all access options for this article.
References
1.
LucasJ.QuickStats: Percentage of adults aged ≥18 years who had lower back pain in the past 3 months, by sex and age group—National Health Interview Survey, United States, 2018. MMWR Morb Mortal Wkly Rep, 2020; 68:1196.
2.
DeyoRA, MirzaSK, MartinBI. Back pain prevalence and visit rates: Estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976), 2006; 31:2724–2727.
3.
Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Ann Intern Med, 2007; 146:116–127.
4.
ChouR, TurnerJA, DevineEB, et al.The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a National Institutes of Health Pathways to Prevention Workshop Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain. Ann Intern Med, 2015; 162:276–286.
5.
DaubresseM, ChangH-Y, YuY, et al.Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000–2010. Med Care, 2013; 51:870–878.
6.
KrebsEE, GravelyA, NugentS, et al.Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE Randomized Clinical Trial. JAMA, 2018; 319:872–882.
7.
CherkinDC, ShermanKJ, BaldersonBH, et al.Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: A randomized clinical trial. JAMA, 2016; 315:1240–1249.
8.
ChouR, DeyoR, FriedlyJ, et al.Noninvasive Treatments for Low Back Pain Comparative Effectiveness Reviews. Rockville, MD: Agency for Healthcare Reseasrch and Quality, 2020.
9.
QaseemA, WiltTJ, McLeanRM, et al.Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med, 2017; 166:514–530.
10.
The Centers for Medicare & Medicaid Services. Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N), 2020. Available at https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=295, accessed November15, 2020.
11.
ChoY-J, SongY-K, ChaY-Y, et al.Acupuncture for chronic low back pain: A multicenter, randomized, patient-assessor blind, sham-controlled clinical trial. Spine, 2013; 38:549–557.
12.
ShermanKJ, CherkinDC, WellmanRD, et al.A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med, 2011; 171:2019–2026.
13.
SchneiderM, HaasM, GlickR, et al.Comparison of spinal manipulation methods and usual medical care for acute and subacute low back pain: A randomized clinical trial. Spine, 2015; 40:209–217.
14.
CherkinDC, AndersonML, ShermanKJ, et al.Two-year follow-up of a randomized clinical trial of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care for chronic low back pain. Jama, 2017; 317:642–644.
15.
HedbergK, BuiLT, LivingstonC, et al.Integrating public health and health care strategies to address the opioid epidemic: The Oregon Health Authority's Opioid Initiative. J Public Health Manage Pract, 2019; 25:214–220.
16.
ChooEK, CharlesworthCJ, LivigstonC, et al.Increased use of complementary and alternative therapies for back pain following statewide medicaid coverage changes in Oregon. J Gen Intern Med, 2021; 36:676–682.
17.
EavesER, HsuCW, DeBarLL, et al.Whole systems within whole systems: The Oregon Health Plan's Expansion of services for back and neck pain. J Altern Compl Med, 2019; 25(S1):S61–S68.
18.
R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing, 2013. Online document at: www.R-project.org, accessed February15, 2020.
19.
HarrisPA, TaylorR, ThielkeR, et al.Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform, 2009; 42:377–381.
RobertsK, DowellA, NieJ-B. Attempting rigour and replicability in thematic analysis of qualitative research data; a case study of codebook development. BMC Med Res Methodol, 2019; 19:66.
22.
OnwuegbuzieAJ, DickinsonWB, LeechNL, et al.A qualitative framework for collecting and analyzing data in Focus Group Research. Int J Qual Methods, 2009; 8:1–21.
23.
Kaiser Health Tracking Poll: October 2015. Menlo Park, CA: The Henry J Kaiser Family Foundation, 2015.
24.
O'NealG, ConnorsR. Nearly One in Three People Know Someone Addicted to Opioids; More Than Half of Millennials Believe it is Easy to Get Illegal Opioids. American Psychiatric Association, 2018. Available at https://www.psychiatry.org/newsroom/news-releases/nearly-one-in-three-people-know-someone-addicted-to-opioids-more-than-half-of-millennials-believe-it-is-easy-to-get-illegal-opioids, accessed January15, 2021.
25.
GhildayalN, JohnsonPJ, EvansRL, et al.Complementary and alternative medicine use in the US adult low back pain population. Glob Adv Health Med, 2016; 5:69–78.
26.
HudsonB, HunterD, PeckhamS. Policy failure and the policy-implementation gap: Can policy support programs help?. Policy Des Pract, 2019; 2:1–14.
27.
HedbergK, BuiLT, LivingstonC, et al.Integrating public health and health care strategies to address the opioid epidemic: The Oregon Health Authority's Opioid Initiative. J Public Health Manag Pract, 2019; 25:214–220.
28.
SinnottP.Administrative delays and chronic disability in patients with acute occupational low back injury. J Occup Environ Med, 2009; 51:690–699.
29.
ArnoldE, La BarrieJ, DaSilvaL, et al.The effect of timing of physical therapy for acute low back pain on health services utilization: A systematic review. Arch Phys Med Rehabil, 2019; 100:1324–1338.
30.
FritzJM, ChildsJD, WainnerRS, et al.Primary care referral of patients with low back pain to physical therapy: Impact on future health care utilization and costs. Spine, 2012; 37:2114–2121.
31.
FritzJM, KimJ, ThackerayA, et al.Use of physical therapy for low back pain by medicaid enrollees. Phys Ther, 2015; 95:1668–1679.
32.
OjhaHA, SnyderRS, DavenportTE. Direct access compared with referred physical therapy episodes of care: A systematic review. Phys Ther, 2014; 94:14–30.
33.
IjazN, RiouxJ, ElderC, WeeksJ. Whole systems research methods in health care: A scoping review. J Altern Compl Med, 2019; 25(S1):S21–S51.
34.
RitenbaughC, HammerschlagR, CalabreseC, et al.A pilot whole systems clinical trial of traditional Chinese medicine and naturopathic medicine for the treatment of temporomandibular disorders. J Altern Compl Med, 2008; 145:475–487.
35.
HermanPM, CoulterID. Complementary and Alternative Medicine: Professions or Modalities? Policy Implications for Coverage, Licensure, Scope of Practice, Institutional Privileges, and Research. RAND Corporation, 2015. Available at https://www.rand.org/content/dam/rand/pubs/research_reports/RR1200/RR1258/RAND_RR1258.pdf, accessed October15, 2020.
36.
CunninghamPJ, O'MalleyAS. Do reimbursement delays discourage medicaid participation by physicians?. Health Affairs, 2008; 27(Supplement 1):w17–w28.
37.
SommersAS, ParadiseJ, MillerC. Physician willingness and resources to serve more Medicaid patients: Perspectives from primary care physicians. Medicare Medicaid Res Rev, 2011; 1:001.002.a001.
38.
RosenbaumS.Medicaid payments and access to care. N Engl J Med, 2014; 371:2345–2347.
39.
LiouKT, KorensteinD, MaoJJ. Medicare coverage of acupuncture for chronic low back pain: Does it move the needle on the opioid crisis?. J Gen Intern Med, 2020; 36:527–529.
40.
GriffinKH, NateKC, RivardRL, et al.Referrals to integrative medicine in a tertiary hospital: Findings from electronic health record data and qualitative interviews. BMJ Open, 2016; 6:e012006–e012006.
41.
The Diversity of Oregon's Licensed Health Care Workforce: Based on Data Collected During 2016 and 2017. Oregon Health Authority: Office of Health Analytics, 2019. Available at https://www.oregon.gov/oha/HPA/ANALYTICS/HealthCareWorkforceReporting/2019-02-Workforce-Diversity-for-web.pdf, accessed January15, 2021.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
