Agenda. Oregon Health Plan Back Pain Coverage Changes

Transcription

1 Oregon Health Plan Back Pain Coverage Changes Effective July 1, 2016 Alison Little, MD, MPH Medical Director, Medicaid, PacificSource Community Solutions PR3755_ Agenda History Evidence on treatment of back pain What will no longer be covered What isn t changing How do I access services Questions 1

2 History of Back Pain Coverage Oregon Health Plan benefit package defined by Prioritized List of Health Services Prioritized List was created, and is maintained, by the Health Evidence Review Commission Oregon Health Plan began in 1994 History of Back Pain Coverage Lumbago and other forms of low back pain were initially not in the funded region of the List because of perceived lack of efficacy of treatment Surgical treatment was covered for radiculopathy and spinal stenosis Detailed guidelines require objective evidence of neurological impairment 2

3 History of Back Pain Coverage In 2014, HERC convened the Back Lines Reorganization Task Force to re-examine evidence pertaining to treatment of low back pain Neurosurgeon Chiropractor Acupuncturist Orthopedic Surgeon Primary Care MD Physiatrist Physical Therapist MH / Addictions Specialist CCO Medical Director Pain Specialist Expert on evidence Back Pain Evidence Primary evidence source: Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, J.T. Jr., Shekelle, P., Owens, D.K., Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College of Physicians, American Pain Society Low Back Pain Guidelines Panel. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med, 147(7),

4 What s Covered? Non-invasive treatments: Medications Primary Care office visits Cognitive Behavioral Therapy (CBT) Physical and Occupational Therapy Osteopathic Manual Therapy (OMT) Chiropractic Acupuncture What s Covered? Other non-invasive treatments in some situations (only in setting of contracted provider see handout) Yoga Interdisciplinary rehab Supervised exercise Massage 4

5 How Do I Get it Covered? Begin with validated risk assessment tool (assesses the risk for poor functional prognosis) Example: STarT Back Tool Keele_STarT_Back9_item-7.pdf How Do I Get it Covered? STarT Back Tool My back pain has spread down my leg(s) at some time in the last two weeks. I have had pain in the shoulder or neck at some time in the last two weeks. I have only walked short distances because of my back pain. In the last two weeks, I have dressed more slowly than usual because of back pain. It s not really safe for a person with a condition like mine to be physically active. Worrying thoughts have been going through my mind a lot of the time. I feel that my back pain is terrible and it s never going to get any better. In general I have not enjoyed all the things I used to enjoy. 5

6 Total Score How Do I Get it Covered? STarT Back Tool Scoring: 3 or less 4 or more Sub score Q5-9 3 or less 4 or more Low risk Medium risk High risk How Do I Get It Covered? Refer to a Panel Provider Prior Authorization/Preapproval Required (no change from current) For all patients, four visits automatically approved For more than four visits, submit STarT Back Tool showing medium or high risk 6

7 How Much is Covered? Low Risk: Four visits per episode/any combination Medium and High Risk: 30 visits per year/any combination Exception: CBT covered without visit limitation, based on medical necessity What is No Longer Covered? Epidural steroid injections Lumbar spinal fusion for patients with foraminal or spinal stenosis 7

8 What Hasn t Changed? Criteria for diagnostic imaging MRI still requires: Objective evidence of radiculopathy Markedly abnormal reflexes Segmental muscle weakness Segmental sensory loss EMG or NCV evidence of nerve root impingement Cauda equina syndrome Neurogenic bowel or bladder Long tract abnormalities Suspicion for malignancy Suspicion for spinal infection Where can I read more? You can find additional information including guidance on coding and coverage here: Health Evidence Review Commission Prioritized List of health services ( PrioritizedList.aspx) 8

9 Questions? PacificSource Community Solutions Main Line: (541)