ICER Endorses Payer Coverage for Yoga, Mindfulness for Chronic Back Pain

The Institute for Clinical and Economic Review (ICER) this week said there’s sufficient evidence for payers to cover several alternative therapies—acupuncture, yoga, cognitive behavioral therapy (CBT), and mindfulness-based stress reduction—to manage chronic lower back pain alongside usual care. The announcement follows a public meeting and voting by the California Technical Assessment Forum (CTAF) on ICER’s Final Evidence Report, which found that these therapies offered potential benefits with far fewer risks than opioids or surgery.

ICER called on researchers to study these methods as a way to curb the use of opioids in chronic pain management, in light of the cost of the drugs and the epidemic of addiction now plaguing the health system.

The announcement comes 2 months after a draft report suggested that CBT, yoga, and other therapies could offer additions to usual care for back and neck pain. The final report states that “evidence appears adequate to support coverage” for several therapies for chronic low back pain, but that there is less evidence of effectiveness for chronic neck pain.

ICER found that evidence for tai chi was “promising but inconclusive” for managing back pain. While the evidence for alternative therapies for treating neck pain was weak, ICER said payers could choose to offer coverage on a case-by-case basis.

“Findings from our report and the votes of the CTAF panel suggest that there is adequate evidence to support broader insurance coverage of all of these therapies except for tai chi, where the evidence is still inconclusive. Good studies have shown that these other modalities can reduce pain and improve function for people with chronic low back pain, and they pose fewer risks than opioids or surgery,” David Rind, MD, MSc, chief medical officer of ICER, said in a statement.

“Unfortunately, even in the face of an opioid epidemic, many patients are not offered these alternative types of pain management,” Rind said. “Stakeholders, particularly payers, should work to ensure that patients are able to access a broad range of evidence-based non-drug interventions with at least as much ease as they are able to access pharmacologic treatments.”

The endorsement is something of a breakthrough for mind-body therapies, which have grown in popularity but have struggled to gain widespread acceptance among payers as alternatives to medication or traditional physical therapy worthy of reimbursement. The challenges to payer coverage have been cited in research and were listed in ICER’s report:

• Variation. The very things that define yoga—the unique approach of each instructor, the different poses or activity levels from class to class—don’t fit with the historic approach taken by payers, who tend to assign prices to discrete items or actions.
• Different types of pain. Pain has many causes, and some type of mind-body therapy might work for some types of chronic back pain but be ineffective for others, but the evidence is “not sufficient” to identify all these variations.
• Sustained effects. Most studies of yoga, mindfulness training, cognitive interventions for chronic pain lasted less than a year. Maintenance of behavioral change is a challenge, and would affect long-term benefits.
• Placebo effects. The ICER report cited studies that found “sham” acupuncture produced placebo effects that were almost as pronounced as traditional acupuncture.

As reported this spring in Evidence-Based Diabetes Management™, more and more clinical trials have examined yoga and mindfulness for their health benefits not only in pain management, but also in aiding reducing insulin resistance, depression, anxiety, and improving sleep. In diabetes management, yoga and mindfulness-based stress reduction have been viewed as potential tools, alongside usual care, to help patients manage their disease without progressing to more medication.

The rise of outcomes-based payment models could potentially help mind-body practices overcome their historic problem in managed care: variability. Under an outcomes-based model, if patients met health benchmarks, the fact that classes and teachers varied somewhat might not matter.

Mind-body practices, and yoga in particular, have another thing going for them in the ICER report: they are comparatively cost-effectiveness without the potential harms of standard methods. ICER recommended that payers give enrollees options but not necessarily allow reimbursement for multiple therapies at the same time.

“Because patients may have strong preferences and be inclined to respond favorably to some, but not all, of these management options, payers should consider covering all of these cognitive and mind-body options to maximize the chances for positive outcomes,” the evidence report states.

Maria Parrella Turco, co-founder and president of the New Jersey-based Honor Yoga studios, said she has seen firsthand clients’ successes when yoga helps them overcome back pain and their frustration when financial constraints limit their progress.

“So many times, we have people who cannot afford the therapeutic part of yoga,” Turco said, referring to a program taught by a licensed physical therapist that helps clients who are overcoming injuries or illness. (Yoga therapy is a distinct practice whose practitioners have more education; the field has its own peer-reviewed journal, the International Journal of Yoga Therapy.)

When finances are a problem, Turco said, her studios try to work out arrangements with clients who have therapeutic needs. The level of expertise needed for therapeutic classes “is worthy of reimbursement,” she said. “This could be a game-changer if we could make strides in this area.”