by John Weeks, Publisher/Editor of The Integrator Blog News and Reports

The cornucopia of state-sponsored payment pilots opening doors for integrative pain strategies is spilling new fruit. Two new projects are underway or have been announced, in Washington and Minnesota. Both are responses to the nation’s dependence on pharma and particularly opioids. The first is an acupuncture program offered through the Department of Labor and Industries in the state of Washington. The latter has a broader focus on non-pharmacologic approaches to team-based care for chronixcpain in rehabilitation medicine in Minnesota.

Washington acupuncture association succeeds in creating a L& I pilot

On October 1, 2017, the licensed acupuncturists in the state of Washington began a back pain pilot with that state’s Department of Labor and Industries. The project has long been promoted by the state’s professional group, Washington East Asian Medical Association (WEAMA). The pilot, that will last for a maximum of 2 years, was originally to involve 150 licensed practitioners. Highs levels of interest upped the numbers to 215.

Driving the activity for the WEAMA has been nurse-acupuncturist Lisa Taylor-Swanson, PhD, EAMP [East Asian Medical Provider, Washington’s version of an LAc] who recently took a faculty position in Utah. The general outlines of the program are that patients are treated on referral from L&I for up to 10 visits. In addition, the practitioners will gather outcomes and provide a report on the final visit. Outcomes measures will include the Oswestry Disability Index (ODI) and 2-item Graded Chronic Pain Scale (GCPS). These will be used to assess functional status at baseline, the middle or 5th visit, and then at the end of treatment. According to a report from WEAMA, participants will submit “chart notes as well as functional scores” from these measures.

Some of the history of the association’s work is included in this photographic report from the WEAMA on their research and legislative work. Notably, this included the delivery of an important research product based on five years of effort by WEAMA “and many volunteer researchers within the organization.” On October 3, 2016, a team led by Taylor-Swanson and including Jennifer Stone, LAc, and Megan Gale, MSAOM, DiplOM, EAMP, presented L&I director Gary Franklin, MDS, MPH, with a paper entitled “Acupuncture for Low Back Pain: A Systematic Review of Randomized Controlled Trials.” Just 4 days later, Washington’s governor Jay Inslee convened a summit on the opioid crisis, for which the profession was then well positioned.  (Thanks to acupuncturist Cheryl House, EAMP, DACM for the tip on the story.)

Minnesota’s chronic pain rehabilitation bundled payment pilot for those on medical assistance

The Institute for Chronic Pain has published a backgrounder of what they are calling “a sweeping pilot” in the state of Minnesota of a new payment arrangement through Medical Assistance, which makes it possible “for state recipients of the public health insurance to receive care within an interdisciplinary chronic pain rehabilitation program.” The article portrays Minnesota as the first state to pay for an interdisciplinary chronic pain rehabilitation program “in a viable manner” for those on Medical Assistance.

The legislative language for the trial was inserted in an omnibus health and human services bill from state representative Deb Kiel and state senator Jim Abler. The initiative eventually found broad backing. The state’s HHS Advisory Council provided authorization to seek to “increase use of non-pharmacological, non-invasive pain therapies” for this population. The Institute for Chronic Pain was among the backers.

The usual challenge for team strategies has been a payment structure in which some components might be paid “at low cost, or not reimbursed at all.” This makes such programs, despite supportive research, economically unviable.  Providers have promoted “bundled payment” schemes with employers. This however is the first to extend coverage for this population via a state payment program.

Notably, the ICP’s description of chronic pain specialists is quite limited: psychologist, surgeons and – as though expressing an out-of-the-box option, physical therapists, “an altogether different type of healthcare provider.”  The vision for chronic pain rehabilitation is similarly limited. There is no mention of chiropractic, acupuncture, massage, yoga, or any specifically mind-body approaches. The website of another part of the coalition, the Courage Kenny Rehabilitation Institute, at Allina Health, also provides no evidence of any appreciation of “integrative” non-pharmacologic approaches. A link to a TEDx talk from Tracy Jackson, MD, on interdisciplinary care gives yoga, nutrition and mindfulness a little play.

Comment: Both stories are good news, despite the latter’s omissions. A national leader for integrative pain, Bob Twillman, PhD, the executive director of the Academy of Integrative Pain Management, celebrated the Minnesota initiative as a breakthrough in an e-mail in which he shared it with me.

To the question of inclusion of a broader set of “integrative practitioners,” Twillman says he sees “nothing in the bill that restricts any provider type from being included.” Twillman forwarded the language in the stand-alone bills that were incorporated in the larger Minnesota HHS budget bill. The elements necessary to meet the definition as a “chronic pain rehabilitation therapy demonstration project” were:

  • non-narcotic medication management, including opioid tapering;
  • interdisciplinary care​ coordination;
  • and group and individual therapy in cognitive behavioral therapy and physical​
  • The project may include self-management education in nutrition, stress, mental​ health, substance use, or other modalities, if clinically appropriate.

Bottom line, interdisciplinary pain payment pilots need to be engaged with any provider mix to give insurers comfort in breaking the shackles of single practitioner payment models. Hopefully at a place like Allina with its long connection with integrative at the Penny George Institute and elsewhere, the doors will be open to chiropractors, acupuncturists and others. Go knock!

On the Washington state program, credit the WEAMA and the trio of leaders. They set a strategy, did the work, built the relationships, suffered some defeats, hung in there and got their pilot. Now we await the outcomes.

Editor’s note: This analysis article is not edited and the authors are solely responsible for the content. The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of Integrative Practitioner.