The IOM report “Relieving Pain in America” indicates that racial and socioeconomic disparities in pain treatment are common. There is a paucity of data regarding disparities in innovative pain procedures. Two existing studies discuss profound racial differences in patients receiving advanced pain procedures like neuromodulation (Neuromodulation 2021;24:434-40; Pain Pract 2021;21:75-82). Patients with private insurance have the highest odds of undergoing these therapies, followed by Medicare and Medicaid patients (Pain Pract 2021;21:75-82).

In 2021, the U.S. Census Bureau published a brief titled “Health Insurance Coverage by Race and Hispanic Origin: 2021” using 2021 American Community Survey one-year estimates. The brief examined differences in health insurance coverage for the civilian noninstitutionalized population by race and Hispanic origin. The American Community Survey broadly classifies health insurance coverage as private insurance plans provided through an employer or a union, coverage purchased directly by an individual from an insurance company or through an exchange (such as healthcare.gov), or coverage through TRICARE. Public insurance coverage includes federal programs such as Medicare, Medicaid, and CHIP, individual state health plans, and the Civilian Health and Medical Program of the Department of Veterans Affairs, as well as care provided by the VA. In people aged 19-64, 80% of Whites, 48% of American Indians and Alaska Natives, 63% of Blacks, and 57% Hispanics or Latinos had private insurance coverage. Racial differences existed even among people having the same employment status or income-to-poverty ratio. The employed White and Asian non-Hispanic adults under 65 years old had 20% higher rates of private coverage compared to employed Hispanic, American Indian, and Alaska Native adults (asamonitor.pub/3v0JwQH). In all, Whites are more likely to have access to better reimbursing private insurance plans than their non-White counterparts regardless of employment status.

Lack of insurance coverage for interventional pain procedures and multimodal pharmacologic options, along with unwarranted prior authorization requirements and frequent denials, has plagued the practice of medicine. In some cases, insurance providers continue to reduce coverage for treatment options that have a proven track record of safety and efficacy by simply inappropriately labeling them as “experimental” or “not medically necessary.” This resulted in a lack of access to quality care, which helped precipitate the opioid overdose crisis. It also unnecessarily burdens emergency and inpatient services as pain patients desperately seek relief that has been denied on an outpatient basis by their insurance providers.

Health insurance plans require patients to fail on their preferred medications before a superior prescribed therapy is covered, which delays pain relief and adds to suffering. On the other hand, both Medicare and private insurance groups frequently and unexpectedly change their drug policies, denying patients medication that was previously covered.

In addition to shrinking the scope of coverage, health insurance plans continue to expand the list of pharmacologic and procedural interventions that require prior authorizations – a process that is flawed, excessive, and time-consuming. It adds just another insurance-related barrier to delay quality and effective pain treatment. Internal guidelines for prior authorization are not based on scientific evidence, and rates of denial have skyrocketed in recent years. The appeal process is cumbersome, forcing physicians to spend an enormous amount of time documenting and communicating with insurance personnel. Most doctors hired by insurance companies for peer-to-peer calls do not specialize in pain management. There have been instances where insurance company employees are incentivized to deny cases without an adequate review (asamonitor.pub/4c2Khtl). These practices not only reduce access to pain care and increase health care costs, but also strain the physician-patient relationship and add a significant administrative burden. Not all pain practices have the extensive resources and staffing to deal with these excessive prior authorization requirements. As a result, some clinics have seen dramatic turnover in support staff due to the excessive work burden, which indirectly delays patient care and damages the clinics’ reputations.

Access to insurance-covered, effective, evidence-based pain care is paramount. Person-centered nonpharmacologic, pharmacologic, and targeted interventional treatments provided by multidisciplinary teams in concert with a trained pain medicine specialist are best practices. They should be implemented promptly to reduce disability and patient suffering. Access to adequate insurance coverage for nonopioid medications and nonpharmacologic therapies is important. For acute pain, nonopioid medications can be as effective as opioids. Nonopioid therapies are recommended for the treatment of subacute and chronic pain (MMWR Recomm Rep 2022;71:1-95). Unfortunately, there are often coverage limitations for nonopioid therapies, such as off-label use of medications for specific pain conditions or pain interventions. Lately, health plans have been denying coverage for newer opioids with less abuse potential. Out-of-pocket costs for uncovered or denied treatments may leave them out of reach for many patients.

ASA opposes the misappropriation of the term “experimental” in coverage policies and encourages health plans to follow evidence-based guidelines supported by specialty societies to prioritize pain relief over profits (asamonitor.pub/3vZcz7P). CMS recently published a rule to streamline the prior authorization process for Medicare Advantage, Medicaid, and other government-sponsored health plans and to improve the timeliness and transparency of the denial process (asamonitor.pub/3V52YX5). For pain practices that have experienced the burdens of the prior authorizations process, these steps might be too little, too late.

ASA supports the scaling of telehealth services for pain, which could allow patients and clinical teams access to physician-led pain care across state lines (asamonitor.pub/3vZcz7P). The use of telehealth services increased in response to the COVID-19 pandemic. However, at present, states have varied legal requirements for prescribing and licensure across state lines (asamonitor.pub/3vZcz7P). Patients may have socioeconomic barriers to telemedicine visits, such as limited access to the internet or devices.

ASA is committed to ensuring patient access to high-quality, physician-led, comprehensive nonopioid pain treatments while minimizing the burden on clinicians working to provide for this complex and challenging care.