ICER Finds Some Benefit to Nondrug Treatments for Low Back, Neck Pain

Low back and neck pain are 2 of the most common reasons for patient visits to healthcare providers in the United States, costing an estimated $88 billion in 2013, ranking third after heart disease and diabetes. Total cost for these 2 areas has increased faster than any other group of diagnoses, from $30.4 billion in 1996 to $87.6 billion in 2013.

With much of the nation talking about alternatives to opioids and other medicines for pain relief, including the possibility of using cognitive and mind-body therapies, late last year The Institute for Clinical and Economic Review (ICER) released a report about 5 interventions for chronic low back and neck pain, as well as the value of those interventions in chronic low back pain.

The strength of the evidence to support alternative treatments by insurance companies was stronger for back pain than for neck pain, the review found.

The interventions reviewed were acupuncture, cognitive-behavioral therapy (CBT), mindfulness-based stress reduction (MBSR), tai chi, and yoga.

Low Back Pain

The review found “moderate certainty of at least a small net health benefit” for each of the interventions, with the exception of tai chi. ICER called the evidence of tai chi for low back pain “promising but inconclusive.”

The strength of evidence appears adequate to support coverage of acupuncture, CBT, MBSR, and yoga for chronic low back pain. Evidence is far weaker for tai chi.

Neck Pain

ICER said acupuncture was “promising but inconclusive.” Evidence for all of the other interventions was insufficient. Cost effectiveness was not assessed in neck pain due to a lack of data.

Payers may wish to assess requests for coverage of therapies for chronic neck pain on a case-by-case basis, given the dearth of evidence, ICER said.

The report set value-based benchmark prices for the 5 interventions for low back pain. Value-based benchmark prices for a drug (or non-drug intervention) are defined as the prices that would achieve incremental cost-effectiveness ratios of $100,000 and $150,000 per QALY gained.

The cost per quality-adjusted life year (QALY) ranged from approximately $3,900 for yoga to approximately $93,800 for CBT over a 5-year period.

The report noted that none of these interventions have a single, consistent reported price. No discounts were needed for any of the treatments to achieve $100,000 and $150,000 per QALY cost-effectiveness thresholds, meaning that all of the therapies could have increases in their prices (premiums) and still achieve these QALY thresholds.

• Acupuncture had a value-based benchmarked price of $103.58 per session, and the price to achieve a QALY of $100,000 was $179.66.
• For CBT, a value-based benchmarked price of $211.77 was enough to achieve a QALY of $100,000.
• MBSR had a value-based benchmarked price of $59.38 and the price to achieve a QALY of $100,000 was $224.58.
• For yoga, a value-based benchmarked price of $17.50 was enough to achieve a QALY of $100,000.
• For tai chi, a value-based benchmarked price of $17.50 was enough to achieve a QALY of $100,000.

ICER also considered the budget impact of these therapies and noted that Express Scripts had estimated that its 2017 spending for medications to treat pain and inflammation, including mostly generic NSAIDs, gamma-aminobutyric acid (GABA) analogs, and opioids, will total $4.46 per member per month (PMPM). ICER’s highest budget impact estimate ($0.23 PMPM if 50% of the eligible population were treated with MBSR) would represent only 5% of this PMPM spend.

Researchers should study the effect of these interventions in reducing or eliminating the use of opioids therapy in patients with chronic pain, ICER said.