Experiences of Nonpharmacologic Providers Implementing the Oregon Back Pain Policy Expanding Services for Medicaid Recipients: A Focus Group Study

Abstract

Introduction:

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.

Introduction

Back pain is one of the most common health complaints among adults,¹ affecting 26% of the population.² Historically, clinicians have frequently treated back pain with opioids despite the lack of evidence of benefit, particularly past the acute period.^3
–5 Opioid treatment is not superior to nonopioid treatments^6,7 and there is growing evidence that nonpharmacologic therapy (NPT) treatments are effective at reducing pain and increasing physical function.⁸ Recently, practice guidelines and payer strategies have taken note. In 2017, the American College of Physicians issued guidelines for back pain treatment that included NPT as a first-line of care⁹ and in 2020, the Centers for Medicare & Medicaid Services announced that Medicare will cover acupuncture for back pain.¹⁰

In 2016, Oregon initiated the Oregon Back Pain Policy (OBPP), a novel statewide effort to promote effective back pain care through Medicaid, which is administered via the Oregon Health Plan (OHP). The policy included two parts: (1) coverage of NPTs that have demonstrated evidence of effectiveness⁸ (e.g., physical/occupational therapy, acupuncture,¹¹ yoga,¹² chiropractic manipulation,¹³ massage,¹⁴ interdisciplinary rehabilitation, supervised exercise); and (2) restrictions in acute and chronic opioid therapy and some interventional approaches for chronic pain (Table 1). OHP is implemented through locally governed Medicaid managed care organizations called Coordinated Care Organizations (CCOs). CCOs retained flexibility in tailoring OBPP benefits to their members and in policy implementation. The OBPP stipulated that OHP members with diagnosed acute or chronic back pain receive a coverage benefit minimum of 4 visits for low-risk patients and 30 visits for high-risk patients per year shared across NPT treatment modalities.

Table 1.

Oregon Health Plan Back and Neck Care Guidelines (Effective July 1, 2016)

Increased coverage of NPT

Pain-oriented cognitive behavior therapy

Spinal manipulation (chiropractor)

Acupuncture

Physical therapy/occupational therapy

Massage therapy^a

Yoga^a

Interdisciplinary rehabilitation^a

Supervised exercise^a

Decreased coverage

Opioids

Limitations on acute and subacute prescribing

Noncoverage of chronic opioids, with 1-year taper

Epidural steroid injections

Surgeries

If available.

NPTs, nonpharmacologic therapies.

Early evidence suggests that opioid prescriptions and overdose deaths in Oregon declined in the first year postpolicy enactment¹⁵ and use of NPT among OHP patients with back pain increased.¹⁶ A survey of acupuncturists in Oregon in early 2018 revealed logistical and epistemological challenges implementing the policy.¹⁷ The purpose of this study was to increase understanding of OBPP implementation from the perspective of credentialed NPT providers in Oregon. This study is part of a larger study evaluating the impact of the OBPP on NPT service utilization,¹⁶ medications for back pain, and clinical and economic impacts.

Materials and Methods

To better understand NPT provider perspective on, and experiences in, implementing the OBPP, the authors implemented a cross-sectional, observational study design and conducted three online asynchronous focus groups. These groups consisted of Oregon (1) licensed acupuncturists, (2) chiropractors and licensed massage therapists (LMTs), and (3) physical therapists in February 2020. The study was approved by the OHSU Institutional Review Board (IRB#18725). We used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (Supplementary Table S1) and the Consolidated criteria for reporting qualitative research (COREQ) (Supplementary Table S2) to ensure rigor in our methodology.

Participants and procedures

Participants were recruited by e-mail via contact lists from state accreditation boards for the relevant professions. Since chiropractor board lists were unavailable, the authors recruited chiropractors via invitation in an e-mail newsletter from their local professional association. They randomly selected participants for recruitment using R base package.¹⁸ An initial e-mail and follow-ups were sent to providers between December 2019 and February 2020. The e-mails described the purpose of the study and included an invitation to complete an eligibility screener followed by a short survey online using REDCap.¹⁹ NPT providers were eligible if they had provided services to OHP back pain patients within the past year. A total of 83 NPT providers completed the survey, received a $10 Amazon e-gift card, and were invited to participate in a focus group. Of those, 44 responded to the invitation and participated anonymously in the online asynchronous focus groups and received an additional $65 e-gift card.

Two research staff with training in qualitative data collection and experience conducting focus groups with health care providers comoderated the focus groups (M.G. and K.L.; for full guide see Table 2). The focus groups were open for 48 h, with a new set of questions posed each day. The principal investigator and coinvestigator observed the focus groups. Focus group transcripts were uploaded into NVivo (version 12).

Table 2.

Focus Group Guide

Day 1: Experiences with the OHP back pain policy
1. How/from whom did you learn about the policy?
a. Do you recall receiving any direct communication about the policy? If so, can you describe that communication, including who it was from and the general content (to the best of your recollection)?
b. Which aspects of the policy are unfamiliar to you?
2. Was your practice credentialed to bill OHP for services before the back pain policy change?
a. If so: How, if at all, has the policy change affected your practice?
b. If not: How difficult was the process of getting credentialed to bill OHP? What changes, if any, did you need to make to bill OHP?
3. How has the process for documenting and billing for services gone?
a. What has gone well related to billing?
b. What has been difficult or challenging?
c. How adequate is the reimbursement for services for patients with back pain?
4. Since the back pain policy was implemented, what changes, if any, have you seen in referrals from clinicians related to back pain patients?
a. How has the referral process with clinicians been going?
b. What, if anything, would you like to change about the referral and communication process?

Day 2: Experience with patients, policy improvements
1. What has your experience been like with OHP patients referred to your practice under the back pain policy?
a. What level of interest do you perceive from back pain patients in receiving your services?
b. To your knowledge, what barriers do back pain patients experience to receiving your services?
c. What do you think would help patients to benefit from NPTs for back pain?
d. Compared with back pain patients you may see with commercial insurance, are there differences in taking care of OHP back pain patients?
2. From your perspective, what has worked well for patients about the policy?
a. What do you think about the number of visits per year allowed under the policy?
b. What do you think about any other aspects of the policy (such as requirements related to documentation of clinically significant progress)?
c. How would you change the policy for back pain patients if you could?
3. What communications, if any, have you had with patients or clinicians related to opioids for pain?

OHP, Oregon Health Plan.

Analysis

Analysis was conducted with an immersion/crystallization approach²⁰ by a team that included two social scientists (M.G. and K.L.) and two physicians (E.C. and C.L.). Data immersion started concurrent with the online focus groups, where the research team reviewed the data in real time, noting patterns, discussing data saturation, and insights. To form a codebook postfocus group, two lead analysts (M.G. and K.L.) conducted in-depth data immersion, reading all transcripts multiple times, taking margin notes, and formulating preliminary open and axial codes. The preliminary codebook was discussed by the broader team and edited iteratively in weekly meetings. The lead analysts tested the final codebook, including 5 topic codes, 15 root codes, and 24 child codes, on a random subset of data and then ran a coding comparison query. The analysts conducted a within-theme analysis by chunking data²¹ to understand the complexity of each theme, identifying subthemes and sorting data by the level of consensus/dissent.²² Emergent themes were discussed weekly with the full team for 7 weeks.

Results

Of the 44 participants, most were female (64%), white (93%), and non-Hispanic (86%). The majority worked in a primarily urban environment (80%). Participants were credentialed licensed acupuncturists (45%), physical therapists (30%), chiropractic physicians (20%), or LMTs (4%) (Table 3).

Table 3.

Characteristics of Focus Group Participants

Characteristics	N = 44, n (%)
Gender
Female	28 (64)
Male	16 (36)
Ethnicity
Non-Hispanic	38 (86)
Hispanic	1 (2)
Ethnicity unknown	5 (11)
Race
Asian	2 (5)
White	41 (93)
Race unknown	1 (2)
Credentials
Chiropractic physician	9 (20)
Licensed acupuncturist	20 (45)
LMT	2 (4)
Physical therapist	13 (30)
Dual credentialed: Acupuncture and LMT	1 (2)
Dual credentialed: Acupuncture and ND	3 (7)
Urbanicity
Rural	9 (20)
Urban	35 (80)

LMT, licensed massage therapist; ND, naturopathic doctor.

Several themes emerged: participants (1) varied in understanding of the policy, (2) believed the policy was beneficial to patients, (3) experienced implementation challenges that affected care, and (4) faced reimbursement and administrative burdens (Table 4).

Table 4.

Emergent Themes, Subthemes, and Supporting Quotes

Theme 1: Providers varied in degree of familiarity with the OBPP
General awareness of the policy	I am familiar with the policy as it is written.
Knowledge gaps related to NPT coverage	I had heard of expanded coverage for PT and Chiropractic, but details/specifics were unfamiliar.
Knowledge gaps related to opioid restrictions	As a non-prescriber, the opioid regulations were new.

Theme 2: Providers believed expanding access to NPT and restricting opioids was beneficial for patients
Increased access to NPT is good	Access to physical therapy, acupuncture, and chiropractic is incredible! Otherwise they would all end up in an MDs office over and over again refilling their opioids (many still are, but many have made gains to get off the meds too).
Restricted access to opioids is good	I think the policy makes sense and is a good idea. I'm sure it is frustrating for people who became dependent on opioids, but hopefully it limits generations from experiencing the same issues.

Theme 3: Providers experienced implementation challenges that compromised access to and effectiveness of care
Engaging patients in care is hampered by roadblocks and delays	Referrals from other practitioners is a tedious and stressful process for patients who need care immediately.
	It is the initiation of the follow up that is challenging… The wait time for authorization, followed by finding a spot for them on the schedule after that. Since we can't schedule out in advance, OHP patients sometimes have additional wait times even once they are authorized.
Restrictions in coverage hamper effectiveness of practice
	They now only allow two billable units. This certainly decreases the ability to provide complete and comprehensive care. They do not allow acupuncturists to bill for manual therapy or therapeutic exercise, both of which are within our scope of practice in the state of Oregon.
	With such chronic, non-curable conditions, 30 visits between all modalities is not enough and often leads to patients returning to opioids.
	Most of my patients are compliant with care and are grateful for the pain relief and frustrated that they can usually only come for half of the year before the benefits run out and they are forced to ask for opiates again. Most patients know they are dependent on pain killers, but they also know they are not addicted and they wish medical providers/policy makers understood the difference.

Theme 4: Low reimbursement rates and high administrative burden made it difficult for providers to accept OHP referrals
	Reimbursement is not adequate for most providers. We are only able to accept OHP still because we have a high volume clinic and still barely break even (or possibly take a loss) on OHP patients. For providers that are on a smaller scale, it is impossible sustain working with OHP patients.
	One clinic owner told me it takes four traditional-insurance patients to break even against the financial loss of a single OHP visit. Those clinics that are still taking OHP are doing it out of a sense of social responsibility, not profitability, but I believe this financial harm to the clinic is a major reason so many clinics won't take OHP.

OBPP, Oregon Back Pain Policy.

Theme 1: Providers varied in degree of familiarity with the OBPP

Participants evidenced varied levels of understanding of the OBPP, ranging from high familiarity to low knowledge of policy details. Most participants expressed a basic understanding of the policy but lacked clarity on policy details, including which NPT modalities were covered and specifics related to opioid restrictions.

Participants described learning about the policy indirectly, through word of mouth or on social media; many had not received direct communication from official channels. A few participants acknowledged that the survey was the first exposure to the policy in full, stating, “I was never made aware of the specific policy until now.”

Theme 2: Providers believed expanding access to NPT and restricting opioids were beneficial for patients

Overall, participants agreed that the policy benefited patients by providing access to NPT services. As one described:

From a patient care perspective, the policy is a wonderful step forward. Patients who have had persistent back pain are given their first taste of hope and self-efficacy. They start (slowly) to believe they can learn to manage their own symptoms and improve their function. Participant 44, urban, physical therapist

Another participant stated:

I love that Oregon even offers OHP—many states have no program like this, and especially not acupuncture and chiropractic care for low income folks. OHP patients have better alternative services than I have through my own private insurance! Participant 2, urban, licensed acupuncturist

Although study participants do not prescribe opioids, some recounted conversations with patients regarding the policy's opioid restrictions. Some described patients' aversion to opioids, stating that “most patients want to be off of them” and “most of my patients don't want pain medications of any kind.” Although their accounts of patients' opinions about the opioid restrictions varied, participants agreed that patients were interested in pursuing alternatives to medication. One described:

It is mixed, but overall positive. Most of them are very happy to get access to care that involves options besides medications… Many of them are motivated to make what lifestyle changes they can and are happy to learn they also have access to things like chiropractic and physical therapy. Participant 15, urban, licensed acupuncturist

Theme 3: Providers experienced implementation challenges that compromised access to and effectiveness of care

Although participants supported expanded OHP coverage of NPT, most pointed out challenges they faced implementing the policy. Participants reported that patient engagement in care is hampered by delays due to referral and prior authorization (PA) requirements; and that restrictions in coverage (e.g., restricted billable units and number of visits covered) hinder the effectiveness of their practice.

Engaging patients in care is hampered by roadblocks and delays

Although some participants noted that their CCO did not require referrals, most participants reported that their CCO's referral requirement created a barrier to patient access to NPT by delaying access to care. For example, participant 29, an urban LMT and acupuncturist said, “the referral process definitely creates a barrier that can slow down the process of getting treatment. Some become frustrated and disinterested during the process.”

Other participants described clinicians as gatekeepers of access to NPT, stating that clinicians “don't do anything to educate the patients on the benefit of therapy and WHY they should go” and “just give my phone number to patients,” which relies on the patient having resources and motivation to initiate treatment. Some participants described clinicians facilitating successful referrals, either because they work in an integrated health care facility—“since my referrals are mostly in house it has been smooth”—or because the clinician provides education to the patient. For example, participant 41, a rural physical therapist said, “some PCPs have already started the process of providing the patient with pain science education, which allows for an easier transition in our clinic.”

Participants described delays associated with PA requirements. Although participants noted that the “process for authorization is fairly simple,” many stated that the wait time is detrimental to patient outcomes and creates a barrier to services. Participants reported a range in the length of time between the PA submission and approval from “10–14 days” to “2–8 weeks.” One participant described:

I think the preauthorization period is a significant barrier in effectively treating acute injuries. We know that timely intervention is one of the keys to preventing chronicity and yet we are asking patients to wait long periods for referrals and authorizations. Participant 28, urban, chiropractic physician

Restrictions in coverage hamper effectiveness of practice

Several participants disagreed with the policy's coverage restrictions, including restricted billable units and total number of visits across all NPT modalities. Several acupuncturists were disappointed with the number of covered procedure codes/billable units and found these restrictions hampered care. Participants wanted adequate time to provide education to patients but said that the restricted billable unit “decreases the ability to provide complete and comprehensive care.” For example, participant 16, an urban licensed acupuncturist stated, “I am then torn between providing the care that is [in] alignment with my personal and professional ethics or providing only the level of care that OHP will reimburse for.”

Most participants agreed that 30 visits per year is adequate for one modality but combined across modalities is not enough to be effective. For example, one described:

The services are so limited—Chiro, acupuncture, PT and Massage is all lumped together at 30 visits per year—this is not enough to treat if a patient is getting multiple services. Why are services limited that help treat pain? So, you can prescribe the patient a few opioids and send them on their way without beneficial treatment? Why are [NPT] services seen as sub-par to prescriptive treatment? Participant 5, urban, licensed acupuncturist

Some reported that the combined maximum of 30 visits is hard to track across modalities and can be confusing and frustrating for the patient. Several participants agreed that the number of visits necessary depends on the unique circumstances of the patient and should be determined by the provider and informed by “measurable progress on either function or pain (or both).”

Theme 4: Low reimbursement rates and high administrative burden made it difficult for providers to accept OHP referrals

Most participants described an increase in referrals from clinicians due to the policy—ranging in scale from a “small increase” to a “huge increase.” Some participants attributed much of the increase to being new to their practice and are “much more flexible and willing to work with OHP than senior practitioners with a full practice.”

Some participants said that low reimbursement rates and high administrative burden hampered their ability to sustain their practice when providing care to OHP members. These experiences varied and were more common among solo practitioners and small practices, especially providers who were responsible for the administrative work associated with scheduling and billing. For example, an urban chiropractic physician said, “the low level reimbursement makes it difficult to make a business case for participating as a small business regardless of your personal commitment to provide care to all individuals independent of their means.”

Participants said that providers who continue to accept OHP patients do so out of a social responsibility to care for this population even when there is financial loss. For example, participant 38, a rural physical therapist said, “long term it is a money loser for us, and we continue to treat out of sense of responsibility to our community.” Other participants said that they are “very passionate about being able to treat all demographics regardless of income” and that “it is an honor to serve a population which has been under-served in the past.” These participants shared that they continue to treat OHP patients because it aligns with their value system to care for an underserved population and that it is rewarding for them.

Discussion

The OBPP was intended to reduce reliance on opioids for treatment of back pain and expand access to NPT services through Oregon's Medicaid program. The authors found that although NPT providers believe expanded coverage of NPT benefits patients, many providers lacked a clear understanding of the specifics of the policy and faced challenges in policy implementation.

Providers' support for the policy mirrors national perspectives, in which two-thirds of Americans agree that prescription opioid misuse is a serious problem,²³ half agree that doctors should limit opioid prescriptions,²⁴ and over 40% of low back pain patients are turning to NPT.²⁵ Given the policy's context of dispersed governance²⁶ via heterogenous CCOs and that the policy was not consistently accompanied by implementation guidance and tools, it is unsurprising that NPT providers described varying levels of awareness of the policy. Furthermore, the policy had many components and occurred in the context of other national and local²⁷ efforts related to opioids, adding to the challenge of conveying information clearly and memorably to the health care workforce.

Several providers reported an increase in referrals since the policy was implemented, but experienced roadblocks and delays in engaging patients in care. Providers reported differences by CCO in requirements and workflows for referrals and PAs, and consistently reported delays associated with the referral, PA, and scheduling processes. These findings are important because administrative delays in physical therapy referral increase the odds of an acute pain patient developing a chronic disability²⁸ and are associated with increased medical costs, likelihood of imaging, number of total visits, and likelihood of receiving opioid medications.^29,30 Recent studies suggest that removal of the referral requirement for physical therapy among back pain patients is associated with reduced medical costs,³¹ decrease in medications prescribed, same or better discharge outcomes, and increased patient satisfaction.³²

Several NPTs are built on conceptual models of whole-systems care that include attending to patients' mental, emotional, and physical well-being and their preferences and values,^33,34 and NPT providers are trained to spend time educating and counseling patients.³⁵ The findings from this study echo the survey findings from Oregon acupuncturists who experienced the coverage limitations as a challenge to their ability to provide whole-systems care.¹⁷ Consistent with previous findings from Oregon acupuncturists and documented among other disciplines,^36,37 NPT providers in this study shared that low reimbursement rates and high administrative burden made it challenging to sustain their practice. Those who continued to accept OHP patients expressed a personal commitment to serving low-income populations and were more likely to work in a larger clinic setting with administrative support. This finding is important as the proportion of health care providers who accept Medicaid patients each year is on the decline.³⁸ This is particularly concerning given the shortage of NPT providers accepting Medicaid, especially in rural and poor communities.³⁹

Although the OBPP expanded NPT coverage for OHP patients with back pain, access to services was challenged by delays, implementation roadblocks, and provider reluctance to accept OHP due to administrative burdens and low reimbursement rates. These findings suggest that NPT use among OHP enrollees could be improved by reducing the financial and administrative burden on NPT providers in providing care to this population. In addition, these findings point to a possible bottleneck introduced with the referral requirements implemented by some CCOs. Researchers have explored the cost/benefit of removing the referral requirement as direct access to physical therapy for back pain patients, which has demonstrated promising outcomes.^29

–32,40 Caution may be taken before removing referral requirements for other NPT modalities until additional research has determined whether these outcomes are consistent across disciplines.

This study has several limitations. First, a lack of consistent understanding of the policy is a major finding for this study but may decrease the ability to attribute other findings to the OBPP. While participants shared their concerns about low reimbursement rates and high administrative burden in accepting Medicaid payments, these are common concerns among health care professionals and not specific to the OBPP.³⁶ Second, although the authors asked about the experiences of patients, the responses are second hand. Finally, this sample was homogenous in terms of race, with nearly all NPT providers identifying as white. Although the demographics within this study are racially representative of NPT providers in Oregon,⁴¹ 35% of the OHP patient population identifies as black, indigenous, and person of color,* suggesting that white NPT providers are overly represented in the workforce. Lower levels of use of NPT among OHP patients of color¹⁶ may be related to racial discordance between patient and provider. This lack of concordance may be addressed, in part, cultivating a more diverse and culturally responsive workforce. Future studies should investigate the policy's impact on patients, seek to understand the individual- and practice-level factors that influence an NPT provider's decision to accept Medicaid patients, and identify the implementation supports that would facilitate equitable access to NPTs.

Conclusions

The goal of the OBPP was to improve back pain care for OHP members by increasing access to evidence-based NPT and decreasing reliance on opioid medications. This study revealed that although NPT providers support the policy, implementation was hampered by challenges including delays due to referral requirements and PAs, coverage limitations that hinder providers' ability to provide whole-systems care, and high administrative burden and low reimbursement rates. Future payer policies that expand coverage of NPT for back pain may consider implementing the policy alongside dissemination and implementation strategies that streamline referrals, decrease turnaround times for PAs, and decrease the administrative burden on providers.

Footnotes

Acknowledgments

The authors thank Rani George who engaged in discussion and review of this article. They would also like to express appreciation for the research participants who contributed their time and opinions to this project.

Author Disclosure Statement

Dr. Livingston reports grants from the National Institute on Drug Abuse (NIDA/NIH) for this research and a contract with the Kaiser Permanente Health Research Institute for an advisory role of a research study on this back pain policy. Dr. Livingston previously served as the Associate Medical Director of the Health Evidence Review Commission and is currently employed as the Medical Director of Health Share of Oregon.

Funding Information

This work was supported by the National Institutes of Health, National Institute on Drug Abuse (R01 DA047323-01A1).

Supplementary Material

Supplementary Table S1

Supplementary Table S2

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