State legislative sessions across the country are now in full swing! Here are some major trends we’re seeing related to state pain policy, along with opportunities to take action. You can find all of our opportunities to act here. More will be added soon!

Affordable access to multidisciplinary care

An increasing number of states are looking for ways to expand affordable access to multidisciplinary pain management options, like massage, acupuncture, physical therapy, occupational therapy, and chiropractic care.
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• Kentucky HB 198 would require coverage of 20 visits per “instance of chronic pain” for multidisciplinary care (massage, acupuncture, PT, OT, chiropractic care, pain management, counseling) at the same cost level as seeing a primary care provider.
  • Our take: We strongly support this bill. It exemplifies current best practices in pain care, which indicate that multidisciplinary, multimodal care is the best approach to pain–but recognize that those therapy options must be affordable. We were delighted to have bill sponsor Rep. Stevenson speak at our recent state advocacy webinar, which you can watch here.
    • Take action here.
• Colorado HB 20-1085 would require health plans to provide coverage for at least six physical therapy visits and six occupational therapy visits per year, or 12 acupuncture visits, with a maximum of one copayment per year for 12 covered visits. Importantly, it would also prohibit requiring step therapy or prior authorization for “atypical opioid” (a term yet to be defined in state policy) or nonopioid pain medications. The bill also strengthens state-wide prescription monitoring efforts and allocates funding and resources to addressing substance use disorder.
  • Our take: This a wide-ranging bill that considers improvements in access to pain management as part of efforts to mitigate the opioid crisis. We applaud Colorado for looking to address inadequacies in pain care.
• New Hampshire SB 708 would require that insurers provide coverage for evidence-based, nonopioid treatment of pain, including chiropractic treatment, osteopathic manipulative treatment, and acupuncture treatment, and not have annual or lifetime numerical limits on visits for the treatment of pain.
  • Our take: We strongly support this bill. It lacks some detail about cost-sharing on these therapies, and we would be concerned that to offset the costs of unlimited visits, insurers might significantly raise the cost-sharing burden.
• New York A 2772 requires that every policy providing medical coverage must include coverage for alternative treatment for pain management (like acupuncture, massage, yoga, chiropractic care, etc.). The bill also requires the commissioner establish standards and guidelines for the provision of alternate treatment for pain management under the medical assistance program.
  • Our take: We strongly support any bills that expand affordable access to multidisciplinary care. However, the bill seems very general and passes most of the burden of deciding what exactly is covered, and how, to other state departments. With that in mind, if this passes, it will require keeping a close watch on subsequent regulations and commenting on them to ensure that they cover what will actually help people with pain.

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Mitigating unfair insurance practices

Several states are looking at ways to reduce roadblocks to accessing medications. These cost-saving tactics are known as step therapy or fail first (when a patient is required to “fail” on a cheaper alternative medication before an insurer will cover what their clinician prescribed) and nonmedical switching (when insurers make changes to medication coverage midyear).
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Step therapy

• Iowa HF 2089 & SB 3117 would protect patients from step therapy or fail first during the plan year, and from year to year, if the prescription was previously covered.
  • Our take: Year-to-year coverage of medication, even between open enrollment periods, is a big deal. It’s great for patients, but insurers are likely to be resistant.
    • Take action here.
• South Dakota SB 155 doesn’t ban step therapy, but instead offers a clear path to appeal when medically necessary.
  • Our take: The House Health and Human Services Committee just voted the bill out of committee. It now heads to the full House for a vote, which is great news. We’re hopeful it will pass!
• Arizona: HB 2420 would help rein in step therapy practices by allowing patients to obtain exemptions.
  • Our take: This is such a reasonable ask of insurers for the sake of patient safety; we are very optimistic the bill will become law. It recently passed in the House; now it moves to the Senate.

Nonmedical switching

• Pennsylvania HB 853 would ban formulary coverage changes during a policy year when the person has already received some care under that coverage.
  • Our take: There has been some positive momentum on the bill, including local news coverage of patient testimonies. We hope it continues to capture attention.
• Florida SB 696/HB 561 enable the patient’s physician to override a medically inappropriate formulary switch; they also place some formulary change reporting requirements on insurers.
  • Our take: A great start, but we wish the bill went further and prohibited changes outright.
• Connecticut HB 5361 was just recently introduced and would eliminate midyear formulary changes. A hearing was held on March 3, with a number of groups and individuals testifying in support of it.
  • Our take: We appreciate the straightforwardness of this bill and that it fully protects patients from unfair coverage changes and resulting medication switches.

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Provider education on pain

We’re pleased to see an uptick in bills having to do with provider education. Presently, most clinicians receive minimal training on pain management. Several states are looking to correct this, recognizing that a better understanding of how to treat chronic pain could also help alleviate the opioid crisis.
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• New York A 608 would create a state chronic pain management education and training council, an expert panel that advises the commissioner and commissioner of education on how to improve pain care. Members could include patient advocates.
  • Our take: In theory, this is a great step! But it can be challenging to ensure a state follows through on setting up advisory councils.
    • Take action here.
• New York A 9067 would require certain medical professionals (including nurses, psychologists, certain social workers, mental health counselors, physical therapists, physical therapist assistants, and occupational therapists) to complete two hours of training every registration period on topics to prevent or address substance use disorder–including “techniques for managing pain.”
  • Our take: We are glad to see this would enhance education on pain, but it only does so in the context of substance use disorder. We’d love to see the bill require two hours of training in pain management, in addition to the two hours of training on substance use disorder.
    • Take action here.
• Oklahoma has a few bills related to education. HB 1735 / SB 1844 would require physician assistants (PAs) to receive either one hour of training per year on substance use disorder or pain management; SB 1917 would require nurses to receive two hours in either area.
  • Our take: Again, this is a great first step! But ideally practitioners would be trained in both areas, which together represent two serious public health crises.

Interestingly, we’ve seen some bills that mandate providers to discuss nonopioid and/or alternative options with patients (for example, Florida HB 743 and South Dakota HB 1219). While this is a good idea in theory, it is difficult to regulate and enforce. We’d prefer to see this mandate come in the form of continuing medical education on all aspects of pain management.
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Opioid dispensing and prescribing

A number of states are continuing to enact policy change surrounding opioid dispensing and prescribing. Many are exploring additional limits on how and when opioids are prescribed (such as requiring a first-time opioid prescription be limited to a seven-day supply), and/or more specific standards when prescribing (such as requiring a detailed patient-provider contract).

We support efforts that try to reasonably curb abuse without unfairly penalizing people with legitimate pain. In light of reports from many people with pain that they have been denied appropriate pain care or forced off medications (despite no signs of abuse), some states are pushing back against sweeping restrictions.
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• New Hampshire SB 546 seeks to codify that clinicians should use their best judgement when prescribing opioids, without being compelled to adhere to specific dosage limits. It suggests some best practices for clinicians who prescribe opioids for pain (e.g., patients should be monitored regularly, be at the lowest dose possible that still manages pain, medication should be continued only if patients experience improved function and quality of life, etc). Uniquely, it includes language stating that patients with pain should not be denied health care, and that pharmacists should not refuse to fill an opioid prescription for pain.
  • Our take: We strongly support this bill. It could hit a legal stumbling block as far as limiting pharmacists ability to refuse prescriptions.
• Rhode Island SB 2386, which stems from the advocacy of Claudia Merandi and associates of the Don’t Punish Pain rallies, defines “chronic intractable pain” and would clarify that patients diagnosed with chronic intractable pain do not need to be subject to the 2016 Centers for Disease Control (CDC) and Prevention guidelines on opioids, which recommend certain dosage limits.
  • Our take: We support this bill. The bill aims to reverse and reduce the adverse impact that the CDC Guidelines have had on patient access to opioids for chronic pain for those patients that were doing well on opioids. It makes sense to clarify that individuals with high-impact pain, who have failed on other treatment options, may need opioids to manage their pain.
• Washington HB 2807aims to protect providers who prescribe opioids and are “acting in good faith” so that they are not subject to civil liability or disciplinary action. The patient receiving the prescription must have requested the prescription and have provided written informed consent.
  • Our take: We support this bill. However, as written, the language may be too broad to pass.

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Medical cannabis

Medical cannabis continues to be a hot button issue. We’ve seen a number of states looking to expand their current programs or establish a medical program for the first time, including: Alabama, Georgia, Indiana, Iowa, Kansas, Kentucky, Mississippi, Nebraska, North Carolina, South Carolina, Tennessee, and Wisconsin.
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• Alabama SB 165 would create a medical cannabis program, and would include “chronic pain” as a qualifying condition.
  • Our take: We greatly appreciate medical cannabis programs that include coverage for chronic pain, rather than a large number of specific conditions, which frequently means individuals with rare or nonspecific conditions do not qualify.
    • Take action here.
• Kentucky HB 136 would create a medical cannabis program for the first time. The bill includes “chronic pain” as a qualifying condition. It also creates a pathway to approval for minors who meet medical requirements.
  • Our take: A very promising bill, which has 51 total sponsors, so we’re hopeful it will pass.
    • Take action here.
• Rhode Island H 7218 / S 2544 is a bill our Co-Director of Medical Cannabis Advocacy, Ellen Lenox Smith, has helped work on. It helps address some of the access issues to medical cannabis, for example, by discounting costs by 30 percent for those who receive Supplemental Security Insurance, Social Security Disability Insurance, or Medicaid.
  • Our take: A great bill. It’s wonderful that more states are creating programs for patients to legally access medical cannabis as a treatment option, but we must ensure they can reasonably afford it.

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