HERC to reconsider OHP pain coverage

May 10, 2019

Commission to reopen back pain guidelines, continue considerations on chronic pain proposal May 16

The Oregon Health Authority (OHA) announced today that the Health Evidence Review Commission (HERC), will reopen discussions on the coverage guidelines related to neck and back pain implemented in 2016, beginning this winter.

OHA and HERC leadership said that new evidence regarding opioid therapy and opioid tapering that have emerged over the past year warranted another look at the back pain guidelines. At its May 16 meeting HERC will continue its deliberations on the chronic pain proposal currently under consideration, lifting a pause requested by OHA leadership while a third-party review was underway.

"The evidence on the effectiveness of opioid therapy for chronic pain and opioid tapering are limited, but rapidly growing," said Dana Hargunani, M.D., chief medical officer at OHA. "We are grateful to the HERC for facilitating thoughtful, methodical deliberations in the face of limited evidence."

In 2016 the HERC expanded Oregon Health Plan coverage for neck and back pain, newly approving non-pharmacological services such as physical and occupational therapy, cognitive behavioral therapy, acupuncture and yoga. The benefit package also included a one-year timeline to taper neck and back pain patients from long-term opioid therapy.

In 2017 OHA convened the Chronic Pain Task Force to explore whether a similar expansion of services should be offered for OHP patients with five other chronic pain conditions: chronic pain due to trauma, post-procedural chronic pain, chronic pain syndrome, other chronic pain, and fibromyalgia. Currently, these conditions are not intended to be covered by OHP.

The proposal that was informed by the task force garnered considerable concern and attention from advocates, providers and experts across the country, prompting deeper dives into the evidence. Most recently OHA commissioned a third-party review by Washington-based Aggregate Analytics Inc. (AAI) to evaluate how closely the proposal aligned with available evidence.

"The past year has been a valuable learning experience for OHA and the HERC," said Kevin Olson, M.D., HERC chairman. "Not only will we apply what we learned to the chronic pain proposal currently under consideration, we feel there is enough new evidence to reopen the 2016 back pain guidelines to ensure our policies align with our best understanding of clinical evidence. I want to thank the advocates and experts who have voiced concerns and directed our attention to new information."

On May 16 the HERC will be presented with findings from AAI’s report alongside their options to consider regarding coverage for the five chronic pain conditions.

The key findings of the report include:

1. The evidence review conducted by HERC staff was limited to adults, but children and adolescents with these conditions may be included in the coverage under consideration.
2. In some cases, effectiveness of an intervention was extrapolated from literature regarding other chronic pain conditions (e.g., back pain or osteoarthritis) due to limited evidence across the range of diagnoses that could be studied as "chronic pain."
3. The overall evidence to support many of the interventions for chronic pain is sparse.
4. The cited evidence is inadequate to support the exclusion of fibromyalgia for the use of opioids either in the short or long term.
5. There is very low evidence on opioid tapering.
6. An expanded search for high-quality systematic reviews and evidence-based clinical guidelines may be of benefit.

"We want to thank AAI for their rapid and thorough review," Dr. Hargunani said. "Many of the key findings from the AAI report have previously been discussed at HERC meetings or represent challenges that the HERC must frequently consider in face of limited evidence. The AAI report and its key findings will need to be considered closely by the HERC during their final consideration of the proposal."

The three options OHA staff will present for HERC’s consideration include:

• Option 1: Make no changes to the coverage for five chronic pain conditions and their treatments due to insufficient evidence of effectiveness.
• Option 2: Adopt the modified Chronic Pain Task Force proposal for reprioritization of the five conditions and their treatments, as presented at the March 2019 Value-based Benefits Subcommittee (VbBS)/HERC meetings
• Adds coverage for various non-pharmacologic therapies such as cognitive behavioral therapy, physical therapy and acupuncture.
• Adds coverage for non-opioid pharmacologic therapies such as gabapentin, pregabalin and duloxetine.
• Adds coverage for opioid therapy for four of the five conditions for appropriate patients.
• Option 3: Adopt a further revised proposal for reprioritization, informed by the recent AAI evidence appraisal and public input, as modified by OHA staff.
• Adds all benefits from option 2.
• Additional options for consideration related to long-term opioid therapy coverage, including for fibromyalgia.

The HERC will meet from 1:30 to 4:30 p.m. at the Clackamas Community College Wilsonville Training Center, Rooms 111-112, 29353 SW Town Center Loop E in Wilsonville. The full meeting materials, including the AAI report, can be found on the OHA website.

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