As college basketball coach Bobby Knight was purported to have said, “You have to get into position to be in position.”
By the end of 2017, the integrative health and medicine community got into position to play the leading role in balancing the treatment of chronic pain and addiction by ensuring the availability of non-pharmacologic integrative options as a first line treatment. The year ended with a flurry of actions that capped the preceding two years, during which non-pharmacological pain treatment options had attained serious affirmation by conventional medicine organizations like the American Medical Association and the American College of Physicians. Most recently:
- The Joint Commission: the primary accreditor for most hospitals released its “New and Revised Standards Related to Pain Assessment and Management:” As of January 1, 2018, its hospitals must provide non-pharmacologic pain treatments.
- The Integrative Pain Policy Congress: An unprecedented gathering of 50 of the nation’s leading conventional medicine, pain management, and integrative healthcare organizations met in San Diego, California in October to begin the process of formulating the consensus definition for “integrative pain management” in order to influence reimbursement policy.
- Formation of the Congressional Caucus on Integrative Health & Wellness: Established by Colorado representatives Mike Coffman (R) and Jared Polis (D), the caucus will act as a “non-partisan educational forum for legislators,” for current information and research and to discuss legislative potential.
- “Evidence-Based Non-pharmacologic Strategies for Comprehensive Pain Care,” a whitepaper prepared by the Academic Consortium for Integrative Medicine and Health (ACIMH) is the most comprehensive research report on the subject.
These sustained efforts to move integrative non-pharmacologic treatment options to a primary position for chronic pain and addiction treatment could also have the secondary effect of opening the insurance coverage door a little wider for other integrative treatments. To this end, a modest nudge took place in June at the nation’s most important health insurance payer, the Centers for Medicare and Medicaid Services (CMS). Last June, a colleague and I met with Patrick Conway, MD, the then-acting administrator of CMS and director of its Center for Medicare and Medicaid Innovation, CMMI, in Baltimore as a follow up to a question I had posed to him in an April e-mail: “What would it take to bring the licensed providers of integrative healthcare services into CMS payment programs?”
We laid out a map showing the extensive presence of integrative health and medicine clinical services across the country, at hundreds of thousands of independent clinics, at more than 70 medical school-based Centers for Integrative Medicine, at several major private systems, and at an increasing numbers of Veteran’s Affairs (VA) healthcare clinics. We emphasized Medicaid programs and pilots in which integrative approaches were already serving CMS beneficiaries.
Our proposition was that CMS payment programs were (and remain) badly out of synch with licensed services that are readily available in the marketplace. This condition is particularly acute given the established efficacy that integrative treatments have attained treating the types of conditions commonly experienced by CMS beneficiaries. Medicaid pilots in Florida, Rhode Island, and Vermont, as well as new treatment standards in Oregon and Ohio, had all shown good outcomes and cost savings.
The disconnect between market availability and absence of coverage in Medicare and Medicaid had puzzled me since 2014, when I began managing CoverMyCare.org for the Integrative Health Policy Consortium (IHPC). IHPC principals and integrative colleagues had been instrumental in recommending the provisions of the Affordable Care Act in Section 2706 that were designed to end discrimination by private insurers who had historically excluded even licensed providers from coverage. While the intent of the provision’s author, then-Senator Tom Harkin, was clear, the language was not. It said that any licensed healthcare provider should be included in the plans offered by state-licensed insurance companies. It also said that this direction was not an “any willing provider” provision. And Medicare and Medicaid were not included under the law.
CoverMyCare supported the efforts of state-based non-discrimination advocates who had been inspired in part by 2706 to either force their state’s health insurance regulator to adhere to the ACA or to develop their own laws. In 2015, both Oregon and Rhode Island passed statutes whose language mirrored that of 2706. Other states–Hawaii, California, Minnesota, and New Mexico–have worked on similar initiatives. Most of these efforts have been set aside; and the Oregon and Rhode Island laws suffer the same shortcoming–no enforcement–as the federal model. The result: next to no compliance since January 1, 2014.
Meanwhile, the protracted political wrestling in 2017 over the fate of the ACA, and in particular state Medicaid funding, has been offset by the unavoidable, intractable force of the opioid addiction public health crisis. As the epidemic continues to ravage state treasuries, programs and policies like the Joint Commission’s guidance to hospitals, and state Medicaid adoption of non-pharmacologic treatments should continue to attract support. Our meeting at CMS in June complemented these important standards and guideline updates in conventional medicine.
We focused on four areas in which evidence from the marketplace was significant:
- Redressing the pain-prescribing and opioid addiction issues via non-pharmacologic options;
- Covering integrative services for Medicare beneficiaries;
- Support for midwifery services in community health; and
- Reviving the moribund 2706 in order to allow for Medicaid coverage of non-pharmacologic pain and opioid treatment options.
We also emphasized the compelling model of service in the VA’s Whole Health Partnership program that is in its early implementation. This program, carefully evolved within the VA during the last five years, is based on supporting an individual’s health and well being through primary care that encourages clinical directors to include integrative modalities and options (including tai chi and yoga) as part of its supportive care approach. Whole health models like this are of extreme interest to the integrative clinical community.
Conway and his colleagues were open to these ideas. He suggested that waivers might serve to ensure coverage for integrative providers who participate in CMMI programs (notably the Advanced Payment Model (APM) programs, the $10 billion initiative to underwrite U.S. Department of Health and Human Services and CMS objectives to move from fee-for-service to value-based payment models by funding many clinical and administrative pilots.
An early outcome of the meeting was the October attendance by Conway’s colleague, Andrey Ostrovsky MD, the chief medical officer of Medicaid and the Children’s Health Insurance Program (CHIP), at the inaugural Integrative Pain Policy Congress in San Diego, California. Although Ostrovsky has since stepped down, his attendance with a CMS colleague proved to be an eye-opener in terms of observing the number and diversity of leading U.S. medical organizations committed to changing the therapeutic order for pain management.
Ostrovsky’s participation reflected our primary objective for the CMS meeting: to establish an ongoing conversation between CMS and the integrative clinical community. For what may be historic but are now entirely archaic reasons, there has been little involvement between these two communities.
A potentially ripe follow-up conversation could help close that gap, when the Academic Consortium for Integrative Medicine and Health (ACIMH) holds its biennial International Congress on Integrative Medicine and Health in Baltimore in May. CMMI offices are a ten-minute drive across town. Long disconnected from access to the full measure of integrative evidence, CMS leaders would enjoy an all-you-can-eat experience at the Harborplace conference. It is worth noting that the VA’s Tracy Gaudet, MD, who is responsible for carefully nurturing integrative care in the VA and its Whole Health Partnership, is a keynote.
But did we get an answer to our simple question, “What would it take?” Well, somewhat. The answer at this juncture lies in our main takeaways: First, CMS is interested in what they understand about the outcomes and potential cost reductions, but they need more precise data, in particular cost-effectiveness. Second, they depend on stakeholders to make the case for their own involvement in programs like the APM program.
The integrative clinical community has definitely gotten into position to influence CMS coverage policy to include integrative choices for its millions of beneficiaries, beginning with chronic pain and addiction treatment, and moving perhaps, as the VA Whole Health model suggests, to the broader, supported self-care-based paradigm based on wellbeing and prevention. With the new Congressional Caucus on Integrative Health & Wellness in place, and thoroughgoing transformations in pain and addiction policy now accepted, a formidable set of relationships and circumstances could make 2018 a serious year of change for the integrative community.