Welcome back to SpineIQ’s Back Blog! Last week, looked at how social determinants of health can impact potentially spine care.1 This week, we will explore access to care for underserved populations by discussing the study “Increased use of complementary and alternative therapies for back pain following statewide Medicaid coverage changes in Oregon” by Choo et al.2 We believe this study is useful in demonstrating how changes in state-level health policy can directly affect a patient’s ability to access guideline-concordant care for spine-related disorders.  Additionally, increasing access to a variety of treatments will enable researchers to continually evaluate cost effectiveness of these treatments and demonstrate the utilization of prior and current treatments relative to outcomes, patient satisfaction, and value.

Purpose of this study:

Nonpharmacologic treatments for low back pain are recommended by numerous practice guidelines.3,4 Unfortunately, insurance coverage for these treatments is inconsistent especially in Medicaid plans.5 Our discussion last week emphasized the impact of social determinants of health on low back pain, including socioeconomic status, on prevalence and outcomes.1 People of lower socioeconomic status are more likely to be insured by Medicaid, which makes the treatments covered by Medicaid of utmost important to increase equitable access to guideline recommended care.

Several years ago the Oregon state legislature mandated that insurers, including Medicaid, expanded coverage of treatments for low back pain to include several non-pharmacologic treatments. Additionally, the policy included restrictions on opioid prescribing, required tapering plan for patients on chronic opioids, using a validated screening tool (STarT Back) to assess risk prior to opioids, enforcing that first-line therapies be used prior, and enforcing that the respective nonpharmacologic therapies be used in conjunction with opioids. Choo et al took advantage of the ‘natural experiment” created by this policy change to determine if increased coverage would lead to an increase in utilization of such care.


Coverage was expanded to include the following treatments:

  • Acupuncture
  • Chiropractic manipulation
  • Cognitive behavioral therapy
  • Osteopathic manipulation
  • Physical therapy
  • Occupational therapy
  • Yoga
  • Massage
  • Exercise

CPT codes were used to identify the amount of each respective treatment delivered both before and after the policy was implemented.


Prior to policy implementation, around 8% of Oregon Medicaid patients received one or more of the treatments listed above. This number increased approximately four-fold (31%) after the policy was implemented. The proportion of patients receiving chiropractic manipulation grew from essentially zero to more than 10%. In addition, use of physical/occupational therapy went from about 5% to 17%, acupuncture from close to 0% to 5%, and massage from about 2% to about 15% in the same time period.


This study provides evidence that policies created to increase access to treatments routinely offered by conservative spine care clinicians are associated with higher levels of utilization by removing barriers to access. Additionally, the policy allows for safe and effective alternative to opioids by allowing clinicians to have access to other treatments when limiting opioids and reimbursing them appropriately. While many of these policies are largely out of our control as clinicians, this is important information to have when you are talking to elected officials at both the state and national levels.  It is important to recognize that many of these prior coverage policy decisions were viewed in silo’s and a reduction or increase in the utilization of a particular service must be researched to demonstrate the best policy decisions, most appropriate guidelines, and approaches to achieve the best outcomes.


  1. Karran EL, Grant AR, Moseley GL. Low back pain and the social determinants of health: a systematic review and narrative synthesis. Pain. 2020;161(11):2476-2493. doi:10.1097/j.pain.0000000000001944
  2. Choo EK, Charlesworth CJ, Gu Y, Livingston CJ, McConnell KJ. Increased Use of Complementary and Alternative Therapies for Back Pain Following Statewide Medicaid Coverage Changes in Oregon. J Gen Intern Med. 2021;36(3):676-682. doi:10.1007/s11606-020-06352-6
  3. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367
  4. National Guideline Centre (UK). Low Back Pain and Sciatica in Over 16s: Assessment and Management. National Institute for Health and Care Excellence (UK); 2016. Accessed June 11, 2021. http://www.ncbi.nlm.nih.gov/books/NBK401577/
  5. Heyward J, Jones CM, Compton WM, et al. Coverage of Nonpharmacologic Treatments for Low Back Pain Among US Public and Private Insurers. JAMA Netw Open. 2018;1(6):e183044. doi:10.1001/jamanetworkopen.2018.3044