PHARMACIST STEVE

http://woodtv.com/2017/10/29/pain-relief-denied-insurer-stops-covering-popular-therapy/

GRAND RAPIDS, Mich. (WOOD) — Alex Ostrowski has worked hard to control her pain. Now, she fears it will control her again.

“I would describe where I was at 10 years ago as a fog,” Ostrowski said.

Ostrowski, now 30, was first prescribed opioids at age 14.

“You’re controlling your pain, but at the price of normal interaction, at the price of normal quality of life,” she explained.

Ostrowski’s chronic back pain stems from injuries she suffered in a horrific accident on the Sparta lake where she grew up. Ostrowski was 12 years old when a boat ran over her Jet Ski on Camp Lake, pinning her body between its propeller and the wooden slats of the boat’s diving board.

“The propeller cut into the entire left side of my body, in to my stomach, into my intestines, completely crushed my hip and my pelvis,” Ostrowski said.

Incredibly, doctors were able to save not only her life, but also both of her legs. They used metal rods to rebuild her left hip and pelvis.

But the extensive physical trauma led to excruciating chronic back pain and years of overmedication on opioids.

“It was a dark place. It was a very dark place,” Ostrowski said of her years on painkillers.

PATIENT COVERAGE CUTS “TERRIFYING”

Six years ago, Ostrowski found Javery Pain Institute in Grand Rapids, which helped her get off high-dose opioids and find a procedure called facet joint injections that provided the pain relief she desperately sought. In that procedure, small amounts of anti-arthritic steroids — not opioids — are injected into the patient’s spinal joints.

“It’s given you your life back,” Dr. Keith Javery, who is board-certified in anesthesiology and pain management, said during a recent consultation with Ostrowski at the clinic on Kenmoore Drive SE. “With those injections, you were able not only to get back to work, but get into a supervisory role.

“It kills me that the insurance company is no longer allowing us to do those therapeutic facet injections,” Javery said.

Ostrowski is trying alternative procedures, but so far has nothing has worked as well as the facet injections.

“I feel like I’m being punished because I don’t want to take pain medications and that seems so backwards,” she said. “It’s terrifying. I feel almost pushed back into that place by them denying coverage of this procedure. They leave you no other options.”

According to Javery, new restrictions on the kinds of injections and the number of procedures allowed per visit are hurting hundreds of patients at his clinic alone.

DOCTOR: PAIN TREATMENTS ‘LITERALLY SAVE LIVES’

In late 2016, Blue Care Network, one of Michigan’s biggest insurers and a subsidiary of Blue Cross Blue Shield of Michigan, stopped covering the commonly used spinal joint injections for long-term pain relief — the kind of treatment Ostrowski was getting.

The change came after the insurer hired an outside benefits management company, South Carolina-based eviCore Healthcare, to handle interventional pain claims for members.

EviCore considers therapeutic facet injections “experimental, investigational or unproven,” according to its clinical guidelines.

>>PDF: eviCore clinical guidelines

“All these things that we can do to reduce the need (for opioids) are being rapidly in real time denied and not authorized by insurance companies that have been authorizing these for decades,” Javery explained.

“These treatments literally save lives,” he argued.

BLUE CARE NETWORK: NO HIGH-LEVEL EVIDENCE-BASED SUPPORT FOR INJECTION

Blue Care Network confirmed to Target 8 that its coverage guidelines on facet joint injections have changed.

“Blue Care Network’s current policies and coverage guidelines align with eviCore’s and are based on proven, clinical best practices,” Dr. Marc Keshishian of Blue Care Network wrote in an email to Target 8. “Our approach is to take responsible steps to eliminate unnecessary care and expenses in the health care system that drives up costs for our customers and members, by using clinically valid determinations that ensure our members get the most appropriate and effective care at the right time on their path to wellness.

“There’s no high-level evidence-based medicine supporting therapeutic facet joint injections,” Keshishian, the senior vice president and chief medical officer for Blue Care Network, continued.

Pain physicians themselves acknowledge there’s a lack of high-quality, large-sample studies on interventional pain procedures. They say that’s partially because it’s difficult to recruit subjects for double-blind pain studies in which some participants will receive placebos.

But Javery said he doesn’t need “high-level evidence” because he sees the results every day.

“The pain relief is drastic,” he said.

Many insurers still cover facet joint injections for long-term pain relief, though the number per year is limited, often to five sessions per region per year. Medicaid and Medicare are among those that cover the injections, though Michigan’s Medicare administrator told Target 8 supporting evidence for their use is “not strong” and that Medicare covers them simply because the procedures have been done for a long time.

It’s clear there’s no broad consensus across the health care industry on best practices for pain management.

In fact, Blue Care Network’s own medical director for behavioral health told Target 8 his experience supported the use of facet injections.

“Facet blocks have been around since I started practice,” Dr. William Beecroft of Blue Care Network said. “They’re very effective. They work very well with relatively low side effects, adverse reactions to them. There are some better procedures now looking at a treatment plan, but if they work for the individual and consistently work for that person, it’s illogical they would be stopped.”

Blue Care Network initially provided Beecroft for a sit-down interview with Target 8 because the insurer thought the story focused on opioids, not changes to pain treatment coverage, though Target 8 specified the latter in a prior email exchange.

In response to a list of questions Target 8 submitted after the interview with Beecroft, Blue Care Network said the concerns regarding coverage cuts “appears to be an isolated complaint by a specialist and members.”

The complaint is not isolated.

MICHIGAN PAIN CONSULTANTS: “PATIENTS FEEL TRAPPED”

Michigan Pain Consultants is also frustrated by the reductions in coverage.

“Patients feel trapped,” said Lisa Pearson, executive director of Michigan Pain Consultants, one of the state’s largest networks of clinics.

“Limited on the injections. Limited on the narcotics. High co-pays and deductibles for physician therapy and behavior therapy, both important to treating chronic pain in a comprehensive fashion,” she wrote in an email to Target 8.

Pearson said the biggest issue for patients is the reduction in what injections they are allowed to get and how often they can get them, especially with facets and epidurals.

“Patients with whom our physicians have worked for months or years to dial in the best pain relief possible with the fewest side effects are told that despite the fact that we document the injections wear off at week 7 or 8 or 9 are told that they have to wait another 3 or 4 or 5 weeks in severe pain before they get treatment. If we could magically make depomedrol (an anti-inflammatory steroid) last longer than it lasts, we’d do so,” Pearson said.

“What is the point of even having physicians, if the insurance companies and companies like eviCore ultimately override the physician’s decisions? This is an extremely dangerous path that we are going down,” Pearson argued.

EVICORE: GUIDELINES “GROUNDED IN STRONGEST EVIDENCE-BASED MEDICINE”  

For its part, eviCore told Target 8 in an email that its coverage guidelines are “grounded in the strongest evidence-based medicine published to date.”

“Pain complaints, most of which are attributed to musculoskeletal conditions, impact more than 116 million Americans annually, making it critical that we ensure these patients are receiving the type of evidence-based care that best positions them for successful outcomes,” wrote Robert W. Westergan, M.D., chief of musculoskeletal programs for eviCore.

“EviCore’s guidelines, first and foremost, reflect the most current, evidence-based criteria and peer-reviewed literature available. These guidelines are completely transparent and available for anyone to view,” Westergan wrote. “Our only goal is to ensure that the patient receives the most appropriate, evidence-based care for his or her situation. Evicore’s clinical reviews make determinations following the Evicore evidence-based clinical criteria, even if that results in a more expensive episode of care.”

PATIENT WILL ASK STATE TO REVERSE DENIAL 

Meanwhile, Alex Ostrowski is trying alternative treatments, though none have worked as well for her as facet joint injections did.

The newly married marketing manager can’t afford to pay out of pocket for the four times yearly injections. One series of the treatments (she gets several shots at a time) would cost her more than $800.

Her appeal to eviCore and Blue Care Network has been denied, but Ostrowski has every intention of asking the state to review her case.

Michigan’s Department of Insurance and Financial Services conducts external reviews of cases that qualify under the Patient’s Right to Independent Review Act. DIFS can reverse a denial and order an insurer to cover the denied treatment, medication or device.

Here are the outcomes from PRIRA reviews from DIFS 2016 annual report:

Health Benefit Claims

• New Requests for External Review: 887
• General Insurance: 576
• HMO/AFDS: 311

Commercial Insurers

• Number of Orders issued and the Carrier’s Position was Upheld: 222
• Numbers of Orders issued and the Carrier’s Position was Reversed: 78
• Cases Resolved before issuance of an Order: 56
• Not Accepted, Dismissed or Withdrawn: 193

Health Maintenance Organizations (HMO)/Alternative Financing Delivery System (AFSD)

• Numbers of Orders issued and the Carrier’s Position was Upheld: 84
• Number of Orders issued and the Carrier’s Position was Reversed:  42
• Cases Resolved before issuance of an Order: 23
• Not Accepted, Dismissed or Withdrawn: 146

—–

Filed under: General Problems