A Naturalistic Experiment Evaluating the Impact of Medicaid Treatment Reimbursement Changes on Opioid Prescribing and Patient Outcomes Among Patients With Back Pain
Condition: Back Pain; Neck Pain
MeSH terms: Back Pain; Neck Pain
Study type: Observational

Summary: 
      Back on Track is a quasi-experimental, mixed-methods study of a unique natural experiment
      that will answer the question: what is the comparative effectiveness of different payer or
      health-system strategies that aim to prevent unsafe opioid prescribing? The State of Oregon
      is enacting a Medicaid reimbursement policy to enhance access to evidence-based
      non-pharmacotherapeutic treatment options while restricting reimbursement for opioids for
      back pain. We will assess whether the policy decreases unsafe opioid prescribing and improves
      patient outcomes compared with usual back pain treatment practices in a comparable state,
      California, that is not changing Medicaid payment policy.
    

Detailed description: 
      Back pain is one of the most common reasons patients seek medical care, and it can have a big
      impact on patients' quality of life and functioning. Patients and providers are becoming more
      frustrated with common back pain treatments like the long-term use of opioid medications and
      steroid injections, which have been shown to have limited long-term impact on patients' pain
      and day-to-day functioning and can have safety risks.

      The State of Oregon recently changed what back and neck pain treatments they cover for its
      Medicaid enrollees. This started to affect those insured by Medicaid in July 2016 and was
      implemented by January 2018. These changes ended payments for treatments like long-term
      opioid therapy and injections. They also expanded coverage for nondrug treatments, such as
      acupuncture, osteopathic or chiropractic manipulation, physical/occupational therapy, and
      cognitive behavioral therapy. While experts agree that opioid use must be reduced, Oregon is
      among the first states to try such strong measures to promote nondrug treatments and prevent
      the use of long-term opioid treatment for back and neck pain.

      The Oregon Medicaid reimbursement changes for back and neck pain treatment create the
      opportunity for a "natural experiment." In this mixed-methods, observational study, we will
      evaluate the impact of the reimbursement changes by comparing outcomes among patients with
      back pain in Oregon who will have access to these expanded nondrug treatments to similar
      patients seen in comparable clinics in California where expanded services for back and neck
      pain are not covered by the type of comprehensive payer incentive undertaken in Oregon.

      Specifically, we will use electronic health record, Medicaid claims data, and data obtained
      from a longitudinal patient survey to assess the impact of the changes on:

        -  Patients' pain severity, pain related functioning, and satisfaction with care

        -  Patients' use of pain-related health care services

        -  Opioid use

        -  Unintended consequences, such as the use of illicit drugs (While we expect the Oregon
           Medicaid change to result in many positive changes, limiting the use of opioids and pain
           reducing procedures like injections may motivate some individuals to use drugs that were
           not prescribed by their doctor.)

      In addition, we will use qualitative research methods to characterize the facilitators and
      barriers experienced by patients, health care providers, and clinic administrators and staff
      in adopting the Medicaid reimbursement changes and their satisfaction with the constellation
      of available and utilized services.

      Thus, this study has three components: 1) patient survey, 2) administrative data-based study
      (data-only), and 3) qualitative evaluation. This record focuses on the component of the study
      in which subjects are able to enroll - the patient survey.
    

Observational model: Cohort
Time perspective: Other
Sampling method: Non-Probability Sample
Study population: 
        Patient survey: Medicaid-insured adults age 18-65 years who are diagnosed with back or neck
        pain and receive their primary health care from participating OCHIN member
        federally-qualified health centers in Oregon and California. Patients may have acute or
        chronic pain and may be receiving long-term opioid therapy or not receiving long-term
        opioid therapy.
      
Keywords: Primary Health Care; Analgesics, Opioid; Medicaid