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Shelley Starkey

CMS’ Medicaid Guidance Describes Non-Opioid Options for Pain Management

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A new informational bulletin from the Centers for Medicare and Medicaid Services (CMS) suggests a range of strategies for states to promote non-opioid chronic pain management options within their Medicaid programs by leveraging waivers, bundled payments, and other mechanisms. The bulletin builds upon previous CMS guidance to highlight successful programs already in place in some states and to describe Medicaid authorities at states’ disposal.

This bulletin fulfills a mandate from the package of opioid legislation that passed last year requiring CMS to issue guidance on safer alternatives to opioids for managing chronic pain, and it also aligns with the Department of Health and Human Services’ (HHS) five-point strategy to combat the opioid crisis. Recommendations for states cover a wide range of strategies, including the following:

  • Home and Community-Based Services: States can apply for 1915(c) Home and Community-Based Services (HCBS) waivers to target certain populations by location, age, or diagnosis. This can allow states to target chronic pain management strategies to populations most in need without covering expensive services for all beneficiaries. Additionally, states can use state plan amendments (SPAs) to establish new eligibility groups to allow certain beneficiaries to receive HCBS for a limited period of time with a limited scope of services.
  • 1115 Demonstrations: States can use 1115 demonstration waivers to test treatment options for subsets of the Medicaid population, like a program in Rhode Island highlighted in the bulletin. Rhode Island created a multi-modal, multi-disciplinary program for chronic pain management under an 1115 waiver, and CMS suggests that states could implement similar waivers and design programs that fit their populations.
  • Managed Care: Chronic pain management care can be delivered through a risk-based arrangement. Managed care plans have flexibility to provide alternative pain management services as well as supplemental benefits. Alternatives must be medically appropriate and cost-effective substitutes.
  • Bundled Payments: States may design alternative payment methodologies for chronic pain management services associated with a given condition. In particular, CMS points to bundled payments, under which a state would pay a provider or group of providers one unified rate for pain management services, which could include cognitive behavioral therapy, physical therapy, and education.

CMS also suggests a variety of education and utilization management strategies for opioid prescriptions, including provider education, patient education, mandatory prescribing guidelines, prior authorization, and pharmacy lock-in programs. Read the bulletin in full here.