Physical Therapy Coverage Often Ends When Patients Still Need It

By Jordan Rau, KFF Health News

Mari Villar was slammed by a car that jumped the curb, breaking her legs and collapsing a lung. Amy Paulo was in pain from a femur surgery that wasn’t healing properly. Katie Kriegshauser suffered organ failure during pregnancy, weakening her so much that she couldn’t lift her baby daughter.

All went to physical therapy, but their health insurers stopped paying before any could walk without assistance. Paulo spent nearly $1,500 out of her own pocket for more sessions.

Millions of Americans rely on physical and occupational therapists to regain strength and motor skills after operations, diseases, and injuries. But recoveries are routinely stymied by a widespread constraint in health insurance policies: rigid caps on therapy sessions.

Insurers frequently limit such sessions to as few as 20 a year, a KFF Health News examination finds, even for people with severe damage such as spinal cord injuries and strokes, who may need months of treatment, multiple times a week. Patients can face a bind: Without therapy, they can’t return to work, but without working, they can’t afford the therapy.

Paulo said she pressed her insurer for more sessions, to no avail. “I said, ‘I’m in pain. I need the services. Is there anything I can do?’” she recalled. “They said, no, they can’t override the hard limit for the plan.”

A typical physical therapy session for a privately insured patient to improve daily functioning costs $192 on average, according to the Health Care Cost Institute. Most run from a half hour to an hour.

Insurers say annual visit limits help keep down costs, and therefore premiums, and are intended to prevent therapists from continuing treatment when patients are no longer improving. They say most injuries can be addressed in a dozen or fewer sessions and that people and employers who bought insurance could have purchased policies with better therapy benefits if it was a priority.

Atul Patel, a physiatrist in Overland Park, Kansas, and the treasurer of the American Academy of Physical Medicine and Rehabilitation, said insurers’ desire to prevent gratuitous therapy is understandable but has “gone too far.”

“Most patients get way less therapy than they would actually benefit from,” he said.

Hard caps on rehab endure in part because of an omission in the Affordable Care Act. While that law required insurers to cover rehab and barred them from setting spending restrictions on a patient’s medical care, it did not prohibit establishing a maximum number of therapy sessions a year.

More than 29,000 ACA health plans — nearly 4 in 5 — limit the annual number of physical therapy sessions, according to a KFF Health News analysis of plans sold last year to individuals and small businesses. Caps generally ranged from 20 to 60 visits; the most common was 20 a year.

Health plans provided by employers often have limits of 20 or 30 sessions as well, said Cori Uccello, senior health fellow at the American Academy of Actuaries.

“It’s the gross reality in America right now,” said Sam Porritt, chairman of the Falling Forward Foundation, a Kansas-based philanthropy that has paid for therapy for about 200 patients who exhausted their insurance over the past decade. “No one knows about this except people in the industry. You find out about it when tragedy hits.”

Even in plans with no caps, patients are not guaranteed unlimited treatment. Therapists say insurers repeatedly require prior authorization, demanding a new request every two or three visits. Insurers frequently deny additional sessions if they believe there hasn’t been improvement.

“We’re seeing a lot of arbitrary denials just to see if you’ll appeal,” said Gwen Simons, a lawyer in Scarborough, Maine, who represents therapy practices. “That’s the point where the therapist throws up their hands.”

‘Couldn’t Pick Her Up’

Katie Kriegshauser, a 37-year-old psychologist from Kansas City, Missouri, developed pregnancy complications that shut down her liver, pancreas, and kidneys in November 2023.

After giving birth to her daughter, she spent more than three months in a hospital, undergoing multiple surgeries and losing more than 40 pounds so quickly that doctors suspected her nerves became damaged from compression. Her neurologist told her he doubted she would ever walk again.

Kriegshauser’s UnitedHealthcare insurance plan allowed 30 visits at Ability KC, a rehabilitation clinic in Kansas City. She burned through them in six weeks in 2024 because she needed both physical therapy, to regain her mobility, and occupational therapy, for daily tasks such as getting dressed.

“At that point I was starting to use the walker from being completely in the wheelchair,” Kriegshauser recalled. She said she wasn’t strong enough to change her daughter’s diaper. “I couldn’t pick her up out of her crib or put her down to sleep,” she said.

The Falling Forward Foundation paid for additional sessions that enabled her to walk independently and hold her daughter in her arms. “A huge amount of progress happened in that period after my insurance ran out,” she said.

In an unsigned statement, UnitedHealthcare said it covered the services that were included in Kriegshauser’s health plan. The company declined to permit an official to discuss its policies on the record because of security concerns.

A Shattered Teenager

Patients who need therapy near the start of a health plan’s year are more likely to run out of visits. Mari Villar was 15 and had been walking with high school friends to get a bite to eat in May 2023 when a car leaped over a curb and smashed into her before the driver sped away.

The accident broke both her legs, lacerated her liver, damaged her colon, severed an artery in her right leg, and collapsed her lung. She has undergone 11 operations, including emergency exploratory surgery to stop internal bleeding, four angioplasties, and the installation of screws and plates to hold her leg bones together.

Villar spent nearly a month in Shirley Ryan AbilityLab’s hospital in Chicago. She was discharged after her mother’s insurer, Blue Cross and Blue Shield of Illinois, denied her physician’s request for five more days, making her more reliant on outpatient therapy, according to records shared by her mother, Megan Bracamontes.

Villar began going to one of Shirley Ryan’s outpatient clinics, but by the end of 2023, she had used up the 30 physical therapy and 30 occupational therapy visits the Blue Cross plan allowed.

Because the plan ran from July to June, she had no sessions left for the first half of 2024.

MARI VILLAR AND HER THERAPIST

“I couldn't do much,” Villar said. “I made lots of progress there, but I was still on crutches.”

Dave Van de Walle, a Blue Cross spokesperson, said in an email that the insurer does not comment on individual cases. Razia Hashmi, vice president for clinical affairs at the Blue Cross Blue Shield Association, said in a written statement that patients who have run out of sessions should “explore alternative treatment plans” including home exercises.

Villar received some extra sessions from the Falling Forward Foundation. While her plan year has reset, Villar is postponing most therapy sessions until after her next surgery so she will be less likely to run out again. Bracamontes said her daughter still can’t feel or move her right foot and needs three more operations: one to relieve nerve pain, and two to try to restore mobility in her foot by lengthening her Achilles tendon and transferring a tendon in her left leg into her right.

“Therapy caps are very unfair because everyone’s situation is different,” Villar said. “I really depend on my sessions to get me to a new normalcy. And not having that and going through all these procedures is scary to think about.”

Rationing Therapy

Most people who use all their sessions either stop going or pay out-of-pocket for extra therapy.

Amy Paulo, a 34-year-old Massachusetts woman recovering from two operations on her left leg, maxed out the 40 visits covered by Blue Cross Blue Shield of Massachusetts in 2024, so she spent $1,445 out-of-pocket for 17 therapy sessions.

Paulo needed physical therapy to recover from several surgeries to shorten her left leg to the length of her right leg — the difference a consequence of juvenile arthritis. Her recovery was prolonged, she said, because her femur didn’t heal properly after one of the operations, in which surgeons cut out the middle of her femur and put a rod in its place.

“I went ballistic on Blue Cross many, many times,” said Paulo, who works with developmentally delayed children.”

Amy McHugh, a Blue Cross spokesperson, declined to discuss Paulo’s case. In an email, she said most employers who hire Blue Cross to administer their health benefits choose plans with “our standard” 60-visit limit, which she said is more generous than most insurers offer, but some employers “choose to allow for more or fewer visits per year.”

Paulo said she expects to restrict her therapy sessions to once a week instead of the recommended twice a week because she’ll need more help after an upcoming operation on her leg.

“We had to plan to save my visits for this surgery, as ridiculous as it sounds,” she said.

Medicare Is More Generous

People with commercial insurance plans face more hurdles than those on Medicare, which sets dollar thresholds on therapy each year but allows therapists to continue providing services if they document medical necessity. This year the limits are $2,410 for physical and speech therapy and $2,410 for occupational therapy.

Private Medicare Advantage plans don’t have visit or dollar caps, but they often require prior authorization every few visits. The U.S. Senate Permanent Subcommittee on Investigations found last year that MA plans deny requests for physical and occupational therapy at hospitals and nursing homes at higher rates than they reject other medical services.

Therapists say many commercial plans require prior authorization and mete out approvals parsimoniously. Insurers often make therapists submit detailed notes, sometimes for each session, documenting patients’ treatment plans, goals, and test results showing how well they perform each exercise.

“It’s a battle of getting visits,” said Jackee Ndwaru, an occupational therapist in Jacksonville, Florida. “If you can’t show progress they’re not going to approve.”

An Insurer Overruled

Marjorie Haney’s insurance plan covered 20 therapy sessions a year, but Anthem Blue Cross Blue Shield approved only a few visits at a time for the rotator cuff she tore in a bike accident in Maine. After 13 visits in 2021, Anthem refused to approve more, writing that her medical records “do not show you made progress with specific daily tasks,” according to the denial letter.

Haney, a physical therapist herself, said the decision made no sense because at that stage of her recovery, the therapy was focused on preventing her shoulder from freezing up and gradually expanding its range of motion.

“I went through those visits like they were water,” Haney, now 57, said. “My range was getting better, but functionally I couldn’t use my arm to lift things.”

Haney appealed to Maine’s insurance bureau for an independent review. In its report overturning Anthem’s decision, the bureau’s physician consultant, William Barreto, concluded that Haney had made “substantial improvement” — she no longer needed a shoulder sling and was able to return to work with restrictions. Barreto also noted that nothing in Anthem’s policy required progress with specific daily tasks, which was the basis for Anthem’s refusal.

“Given the member’s substantial restriction in active range of motion and inability to begin strengthening exercises, there is remaining deficit that requires the skills and training of a qualified physical therapist,” the report said.

Anthem said it requires repeated assessments before authorizing additional visits “to ensure the member is receiving the right care for the right period of time based on his or her care needs.” In the statement provided by Stephanie DuBois, an Anthem spokesperson, the insurer said this process “also helps prevent members from using up all their covered treatment benefits too quickly, especially if they don’t end up needing the maximum number of therapy visits.”

In 2023, Maine passed a law banning prior authorization for the first 12 rehab visits, making it one of the few states to curb insurer limitations on physical therapy. The law doesn’t protect residents with plans based in other states or plans from a Maine employer who self-insures.

Haney said after she won her appeal, she spaced out the sessions her plan permitted by going once weekly. “I got another month,” she said, “and I stretched it out to six weeks.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

What Not To Say in the Emergency Room

By Carol Levy

Many years ago, I was a clerk in an emergency room ward. Often the people who came in didn't seem to understand how an emergency room works. Unfortunately, those same misunderstandings exist today.

I have seen a number of online posts and comments by chronic pain patients about their experiences in emergency rooms. The posts tend to be very negative about ERs, often angry, and full of frustration over the way they were treated.

My intention when I started this column was to write about the emergency room experience, and what to expect when you make the choice to go there. I did some research to ensure my facts would still be current, such as how ER departments are configured today.

I found several articles on what not to say to your pain management doctor. To my surprise, the answers mimicked what you should not say in the ER, such as “I just need painkillers” or “I know what I need, just prescribe it.”

Saying that gives the impression that you’re just looking for medication, rather than treatment. It’s not advisable to say that to any doctor, regardless of the situation.  

At the ER, you will first see the receptionist or ward clerk. The next step for most hospitals is the triage person, usually a nurse.  When they ask “What is the reason for your visit?” saying, “I have pain” is not sufficient.

They will inquire about when, where and for how long you’ve had pain, to get a better idea of why you are there. That will help them decide what level of an emergency you are.

It’s important not to expect ER staff to know everything about rare disorders, such as CRPS, trigeminal neuralgia or Ehlers-Danlos syndrome. The chances they have seen or even heard of them are slim. Unfortunately, for many rare disorders, we have to be the ones to educate the staff.

Even if you are in extreme pain, shouting “I have pain!” will not help get what you need. Calmly explaining, as best you can, the cause and level of your pain gives them a better understanding of why you are there, and will help get you seen sooner.

Another “don’t” is asking for a specific opioid, as it can make you appear to be a drug seeker. That’s not fair, I know, but that’s just the way it is in the current anti- opioid environment.

Exaggerating your pain can also be seen as the behavior of someone looking to get drugs. Screaming or yelling “I am in horrible pain! Give me something now!” won't get you what you need. Ultimately, the doctor or nurse will decide if you're exaggerating your pain. If they decide that’s the case, you may get nothing at all.

You also shouldn’t question your doctor's expertise. After all, he is the expert (or at least thinks he is). Asking for clarification is fine, but asking for a second opinion may backfire. It’s another way of saying you don't trust or have faith in the doctor. In the ER, you won't be able to get a second opinion. Whichever doctor sees you is the one you’re stuck with.

The wait in the ER may be a long one. The doctors and nurses may seem to be walking around aimlessly, but they may actually be busy, dealing with patients who have suffered a heart attack, stroke, or severe trauma.

If you are a chronic pain patient, your pain may not be seen as an immediate concern. To ER staff, acute pain could be a sign of a life threatening situation that needs immediate attention.

Many ERs now have private rooms, but some still have ward-like areas. It is nice to have privacy, but they may put you in the ward area because that is the only space available.

These unwritten rules apply to everyone on how to act in the ER. But for those of us with chronic pain, we need to to be extra careful about what lines not to cross.

What lessons have you learned in the ER?

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.”  Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here. 

Alarming Study Tries to Automate Labeling of Patients with Opioid Use Disorder

By Crystal Lindell

An alarming new study attempts to automate the process of labeling chronic pain patients with Opioid Use Disorder (OUD), by using a computer to scan doctors’ clinical notes. 

A team of researchers analyzed medical records for over 8,000 patients with chronic pain, and then used an automated process to scan clinical notes from doctors, patient demographics, and diagnostic codes. The automated process was then compared to whether patients had already been given a diagnostic code for OUD. 

The researchers claim that their automated approach out-performed diagnostic codes when it came to finding patients with OUD. The codes are a key part of healthcare and are used by doctors not only to make a diagnosis, but to get reimbursed by insurers for treating patients.  

The authors say the diagnostic codes are “unreliable and underused,” and claim that their automated approach will do a better job predicting which patients are at risk for OUD and which once already have it.

“This automated data extraction technique may facilitate earlier identification of people at risk for and who are experiencing problematic opioid use, and create new opportunities for studying long-term sequelae of opioid pain management,” wrote lead author Alvin Jeffery, PhD, an Assistant Professor in the Department of Biomedical Informatics at Vanderbilt University Medical Center.

Jefferey and his colleagues say chronic pain patients treated with opioids are “at high risk of developing an opioid use disorder,” and cite a single study estimating the risk is as high as 18%. Most research puts the probability much lower, at about 1%.  

There are a number of other alarming things about this research. 

First and foremost, using any sort of automated process to label patients as having opioid use disorder is incredibly dangerous. Especially if that automated process applies the label to more patients than doctors already are. 

Also, the researchers used the “Addictions Behaviors Checklist” to determine if patients have OUD. Unfortunately, that checklist is known for lumping in a lot of patients who simply have untreated or under-treated pain. 

For example, one of the items on the checklist is “patient running out of medications early” – which means anyone who isn’t being prescribed enough pain medication could qualify as having OUD. 

Another criteria on the list is “patient expressing concern about future availability of narcotics” – a normal thing to be worried about when opioid shortages are widespread and opioid-phobia is rampant in the medical community. 

Other red flag terms they search for in doctors’ notes are “hoard,” “stash,” “left over” and “storing.” This also overlooks the fact that prescription opioids can be difficult to get, causing  many patients to keep leftover ones, just in case they needed them in the future. A recent PNN survey found that 32% of patients hoarded unused opioids. 

Once a patient gets labeled with OUD, it can quite literally ruin their lives by making it more difficult for them to get their pain adequately treated. That doesn’t just apply to patients with chronic pain. If a surgical patient experiencing post-op pain (as nearly all do) has “possible OUD” in their chart, doctors are much less likely to prescribe opioid pain medication. 

I genuinely worry that we are reaching a point where computers and artificial intelligence will be used en masse to label patients with damaging mental health diagnoses like OUD. And if that takes root, there won’t be any way for patients to counter the diagnosis. 

In fact, one of the biggest problems in healthcare is that there is no right to due process. Once you are given a medical verdict, so to speak, you are often stuck with it. 

We should all be worried that these types of automated diagnostic tools will also be expanded beyond opioid users to label other patients with stigmatizing mental health conditions that impact the quality of the medical care they receive going forward.

At this point, I’m not sure what patients can even do to stop this from happening, but my hope is that bringing more awareness to the issue will at least slow its progression. 

I personally would judge any doctors who would rely on any sort of automated process to give a patient a dangerous label like OUD, even if such a process is mandated by the hospital they work for, or even the government. 

I hope that doctors will have the moral fortitude to fight back on these types of things. Although if the medical community’s recent history with opioids is an indication, I’m not convinced most of them will stand up for their patients. 

Misinformation About Fentanyl Threatens To Undermine Overdose Response

By Henry Larweh, KFF Health News

Fentanyl, the deadly synthetic opioid driving the nation’s high drug overdose rates, is also caught up in another increasingly serious problem: misinformation.

False and misleading narratives on social media, in news reports, and even in popular television dramas suggesting people can overdose from touching fentanyl — rather than ingesting it — are now informing policy and spending decisions.

In an episode of the CBS cop drama “Blue Bloods,” for instance, Detective Maria Baez becomes comatose after accidentally touching powdered fentanyl. In another drama, “S.W.A.T.,” Sgt. Daniel “Hondo” Harrelson warns his co-workers: “You touch the pure stuff without wearing gloves, say good night.”

While fentanyl-related deaths have drastically risen over the past decade, no evidence suggests any resulted from incidentally touching or inhaling it, and little to no evidence that any resulted from consuming it in marijuana products. (Recent data indicates that fentanyl-related deaths have begun to drop.)

There is also almost no evidence that law enforcement personnel are at heightened risk of accidental overdoses due to such exposures. Still, there is a steady stream of reports — which generally turn out to be false — of officers allegedly becoming ill after handling fentanyl.

“It’s only in the TV dramas” where that happens, said Brandon del Pozo, a retired Burlington, Vermont, police chief who researches policing and public health policies and practices at Brown University.

In fact, fentanyl overdoses are commonly caused by ingesting the drug illicitly as a pill or powder. And most accidental exposures occur when people who use drugs, even those who do not use opioids, unknowingly consume fentanyl because it is so often used to “cut” street drugs such as heroin and cocaine.

Despite what scientific evidence suggests about fentanyl and its risks, misinformation can persist in public discourse and among first responders on the front lines of the crisis. Daniel Meloy, a senior community engagement specialist at the drug recovery organizations Operation 2 Save Lives and QRT National, said he thinks of misinformation as “more of an unknown than it is an anxiety or a fear.”

“We’re experiencing it often before the information” can be understood and shared by public health and addiction medicine practitioners, Meloy said.

Some state and local governments are investing money from their share of the billions in opioid settlement funds in efforts to protect first responders from purported risks perpetuated through fentanyl misinformation.

In 2022 and 2023, 19 cities, towns, and counties across eight states used settlement funds to purchase drug detection devices for law enforcement agencies, spending just over $1 million altogether. Two mass spectrometers were purchased for at least $136,000 for the Greeley, Colorado, police department, “to protect those who are tasked with handling those substances.”

Del Pozo, the retired police chief, said fentanyl is present in most illicit opioids found at the scene of an arrest. But that “doesn’t mean you need to spend a lot of money on fentanyl detection for officer safety,” he said. If that spending decision is motivated by officer safety concerns, then it’s “misspent money,” del Pozo said.

Fentanyl misinformation is affecting policy in other ways, too.

Florida, for instance, has on the books a law that makes it a second-degree felony to cause an overdose or bodily injury to a first responder through this kind of secondhand fentanyl exposure. Similar legislation has been considered by states such as Tennessee and West Virginia, the latter stipulating a penalty of 15 years to life imprisonment if the exposure results in death.

Public health advocates worry these laws will make people shy away from seeking help for people who are overdosing.

“A lot of people leave overdose scenes because they don’t want to interact with police,” said Erin Russell, a principal with Health Management Associates, a health care industry research and consulting firm. Florida does include a caveat in its statute that any person “acting in good faith” to seek medical assistance for someone they believe to be overdosing “may not” be arrested, charged, or prosecuted.

‘You Can Get It Through Your Fingers’

And even when public policy is crafted to protect first responders as well as regular people, misinformation can undermine a program’s messaging.

Take Mississippi’s One Pill Can Kill initiative. Led by the state attorney general, Lynn Fitch, the initiative aims to provide resources and education to Mississippi residents about fentanyl and its risks.

While it promotes the availability and use of harm reduction tools, such as naloxone and fentanyl test strips, Fitch has also propped up misinformation.

At the 2024 Mississippi Coalition of Bail Sureties conference, Fitch said, “If you figure out that pill’s got fentanyl, you better be ready to dispose of it, because you can get it through your fingers,” based on the repeatedly debunked belief that a person can overdose by simply touching fentanyl.

Officers on the ground, meanwhile, sometimes are warned to proceed with caution in providing lifesaving interventions at overdose scenes because of these alleged accidental exposure risks. This caution is often evidenced in a push to provide first responders with masks and other personal protective equipment.

Fitch told the crowd at the conference: “You can’t just go out and give CPR like you did before.”

However, as with other secondhand exposures, the risk for a fentanyl overdose from applying mouth-to-mouth is negligible, with no clinical evidence to suggest it has occurred.

Her comments underscore growing concerns, often not supported by science, that officers and first responders increasingly face exposure risks during overdose responses. Her office did not respond to questions about these comments.

Health care experts say they are not against providing first responders with protective equipment, but that fentanyl misinformation is clouding policy and risks delaying critical interventions such as CPR and rescue breathing.

“People are afraid to do rescue breathing because they’re like, ‘Well, what if there’s fentanyl in the person’s mouth,’” Russell said. Hesitating for even a moment because of fentanyl misinformation could delay a technique that “is incredibly important in an overdose response.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

Poor Oral Health Linked to Fibromyalgia and Migraines

By Crystal Lindell

Poor oral health is significantly associated with body pain, headaches, and abdominal distress in women, according to a new study published in Frontiers in Pain Research. The research highlights the importance of dental hygiene and its role in fibromyalgia and other chronic pain conditions. 

Australian researchers looked at the oral health of 158 women by using the World Health Organization's oral health questionnaire. Over two thirds of the women (67%) had fibromyalgia, a chronic pain condition that causes fatigue, body pain and sleep disturbances. 

Researchers also evaluated saliva samples from the women to look for four oral microbe species that have previously been associated with migraines.

They found that poor oral health scores, higher pain scores, and high microbe levels were significantly associated with each other. That suggests a potential role for the microbes as a cause of the pain experienced by the women. 

“This is the first study to investigate oral health, oral microbiota and pain commonly experienced in women with fibromyalgia, with our study showing a clear and significant association between poor oral health and pain,” said lead investigator Joanna Harnett, PhD, an Associate Professor at the University of Sydney. 

Women with the poorest oral health were more likely to suffer from higher pain scores. Sixty percent experienced moderate to severe body pain, and 49 percent were more likely to experience migraine headaches. Poor oral health was also a significant predictor of frequent and chronic migraine.

Researchers say it’s entirely plausible that poor oral health leads to gum disease and oral dysbiosis, an imbalance of microorganisms that can spread throughout the body. The bacteria then trigger more pain signalling, thus increasing widespread body pain. 

“Our findings are particularly important to fibromyalgia, which, despite being a common rheumatological condition, is often underrecognized,” added first author Sharon Erdrich, a Doctorate Student and Research Assistant at the University of Sydney.

The research is especially interesting because dental health is often cordoned off from the rest of healthcare, at least in the United States. Dental insurance is usually completely separate from regular health insurance, and most doctors will not evaluate your teeth during an appointment. 

Dental care is still often viewed as a cosmetic issue, despite the fact that dental pain is some of the worst pain imaginable. Studies like these show why trying to separate teeth off from the rest of healthcare is a failing strategy. 

Mindfulness and Cognitive Behavioral Therapy Reduce Chronic Low Back Pain

By Pat Anson

Have you tried cognitive behavioral therapy (CBT) or mindfulness? Did they help relieve your pain?

Chronic pain sufferers have been telling us for years that neither form of psychotherapy worked for them. Yet many physicians continue to recommend CBT and/or mindfulness as a safer alternative to opioids and other pain medications.

Does either therapy actually work? And, if so, which one works better?

In the largest head-to-head study of its kind, a team of researchers compared the effectiveness of CBT with mindfulness in 770 patients with chronic low back pain. Unlike previous studies, these patients had fairly high pain levels (an average of 6.1 on a zero to 10 pain scale) and they were taking opioids for at least three months.

The study wasn’t short-term either. Participants were regularly surveyed about their pain levels, physical function, quality of life, and opioid use for up to a year.     

“The people in this study had quite severe back pain that interfered with their life and was bad enough to need opioid medication. Usually, in that condition, people don’t really get better over time on their own,” said co-lead author Bruce Barrett, MD, a Professor of Family Medicine and Community Health at the University of Wisconsin-Madison.

Participants were divided into two groups and trained by experienced therapists in either mindfulness or CBT, before being told to practice them at home daily for at least 30 minutes. Patients trained in mindfulness learned how to “deconstruct” their pain to make it seem less important, while those trained in CBT learned coping, behavioral and relaxation skills.

The study findings, published in JAMA Network Open, show that CBT and mindfulness were equally effective, leading to modest improvements in pain, function and quality of life. The benefits persisted and grew stronger over 12 months, with most participants reducing or even stopping their opioid use.

After a year, the average pain level in the mindfulness group fell to 5.4, while those in the CBT group were reduced to 5.5 on the zero to 10 scale. That’s about a 10% improvement.

“Both mindfulness and cognitive behavioral therapy were shown to be safe, effective treatments, providing lasting benefits for people with opioid-treated chronic back pain. These evidence-based behavioral therapies should be standard of care available to our patients,” wrote lead author Aleksandra Zgierska, MD, a Professor of Family and Community Medicine at Penn State College of Medicine.

Although participants were not explicitly encouraged to reduce their use of opioids, patients in both groups did. Researchers say that was a direct result of their training, which taught them how to cope better with pain and decrease their opioid use on their own.

“These therapies aren’t a total cure, but they teach people how to develop the inner resources they need to cope with chronic pain and to live a better life,” said co-author Eric Garland, PhD, a Psychiatry Professor at the University of California San Diego. “Mindfulness is a self-regulated tool that comes from within, unlike surgery or medication where something is being done to you from the outside. By learning these techniques, patients continue to experience lasting benefit,”

A recent study at UC San Diego using advanced brain imaging found some of the first physical evidence that mindfulness lowers pain intensity by reducing neural activity in parts of the brain associated with pain and negative emotions.

New Guideline Cautions Against Use of Medical Cannabis for Chronic Pain

By Pat Anson

One of the nation’s largest medical organizations has released a cautious new guideline that recommends against the use of medical cannabis for most patients with chronic noncancer pain. The American College of Physicians (ACP) represents over 160,000 internal medicine doctors and medical students in the United States.

The ACP’s “Best Practice Advice,” recently published in the Annals of Internal Medicine, is based on a review of medical cannabis in over three dozen randomized controlled trials and observational studies.

It urges physicians to warn patients that the harms of cannabis and cannabinoid use outweigh their potential benefits. Medical cannabis may produce small improvements in pain, function and disability, but potential harms include addiction and cognitive issues, as well as cardiovascular, gastrointestinal and pulmonary problems.

“This Best Practice Advice is important for practicing physicians when counseling our patients on the potential use of cannabis and cannabinoids to treat their chronic noncancer pain,” said Isaac Opole, MD, President of the ACP.

“As the use of cannabis for medicinal purposes grows it’s critical to open that dialogue and review the emerging evidence related to benefits and harms. We need to raise awareness and get the word out to ensure that patients have the information they need to make informed decisions.” 

The use of cannabis has steadily grown in recent years, with polls showing that nearly one in four U.S. adults have used medical or recreational cannabis at least once in the past year. Although chronic pain is the most common reason patients use medical cannabis, most have never discussed it with their physicians. Many get their information about cannabis from dispensary workers, who typically do not have any medical training.

The ACP recommends against the use of cannabis for chronic pain by young adults and adolescents, patients with substance use disorders, patients with a serious mental illness, patients who are pregnant or breastfeeding, and frail patients at risk of falling. Inhaled cannabis is not recommended for any patients.

There is some evidence that patients with painful neuropathy may benefit from using cannabis products that contain equal amounts of CBD and THC. 

“Evidence shows that in patients primarily with chronic noncancer neuropathic pain, a cannabis formulation with comparable THC–CBD ratio probably results in small improvements in pain severity (about 0.5 to 1.0 points on a zero to 10 pain scale) and function or disability (about 0.4-point improvement on the pain scale),” the ACP said.

“However, the evidence is insufficient to show benefit for other types of chronic noncancer pain. High THC–CBD ratio synthetic or purified products may result in small improvements in pain severity (about 0.5- to 1.0-point on the pain scale) but no change in overall function or disability.”

Currently, 24 states in the District of Columbia have legalized cannabis for adult recreational and medical use. It is legal for medical use only in an another 14 states. 

Research into the pain-relieving benefits of cannabis has been slow in the U.S., largely due to marijuana’s status as a Schedule 1 controlled substance, the same category as LSD and heroin. The DEA dragged its feet on implementing a request from the Biden Administration to reclassify marijuana as a Schedule 3 controlled substance that could be used for medical purposes. Rescheduling marijuana does not appear to be a priority for the Trump Administration.

There are only three cannabis-based medicines approved for use by the FDA: dronabinol and nabilone, which are used to treat nausea and loss of appetite, and a concentrated form of CBD used to control seizures from childhood epilepsy.

A German biotech company is in preliminary talks with the FDA about approving an experimental cannabis extract for chronic low back pain. A recent study in Australia found patients with chronic pain and other health conditions showed significant improvement in their quality of life, fatigue and sleep after taking cannabis oil over a one-year period. There were also small improvements in pain, anxiety and depression.

How Chronic Pain Impacts Romantic Relationships

By Crystal Lindell

The more you love someone with chronic pain, the more likely it is that their pain will cause you emotional distress. 

That’s according to new research published in the Journal of Health Psychology, which looks at the ways middle-aged romantic partnerships are impacted when one person has chronic pain. 

The researchers collected twice-daily surveys over the span of 30 days from 147 couples who were at least 50 years of age and had one partner who suffered from chronic back pain. 

Using the couples' answers to questions about distress and relationship closeness, as well as reports of pain severity from the pain-affected partner, they examined how emotional, behavioral and cognitive closeness affected the quality of couples’ daily interactions.

On the positive side, researchers found that emotional closeness between couples dealing with chronic pain led to more marital satisfaction on days when the couple felt close. 

However, on the other side of things, the closer the couple felt emotionally on any given day, the more likely it was that the non-pain partner experienced more distress. The non-pain partner apparently feels empathy for the pained partner, which results in them feeling stressed. 

As anyone who’s ever been in love knows, empathy is the required price. When your partner is sad, you will also tend to be sad on their behalf. 

This is not inherently a bad thing. Feeling empathy for your partner when they are dealing with pain makes it more likely that you’ll work harder to ease their pain, by doing things like advocating for them in healthcare settings and allowing them to rest while you do the household chores. 

The researchers framed this as something to avoid though, which I guess makes sense if it’s happening excessively.

“Couples have to find a balance that is ideal for them in managing closeness versus independence — this is true for all couples, not just those dealing with the impacts of chronic pain. But for those dealing with chronic pain, we can help them learn how to balance the benefits of closeness with minimizing shared distress stemming from a chronic condition,” lead researcher Lynn Martire, PhD, a professor of human development and family studies at Penn State’s Center for Healthy Aging, said in a press release.: 

The findings suggest that methods could be developed to help couples find the right balance in closeness, which would protect them from causing more pain and distress for each other. Martire and her colleagues plan further studies on the roles of behavioral and cognitive closeness.

“I’m excited to dive deeper into the other research questions we can examine from this data set,” Martire said. “We gathered data using different measures of relationship closeness, how they differ between patients and partners and how relationship closeness changes over time. We are poised to learn a great deal about the impact of pain on couples.”

Prior studies show that closeness is associated with many positive and beneficial relationships, including higher levels of commitment and satisfaction, and a lower risk of the relationship ending. 

However, researchers also say their findings suggest that too much closeness may transfer negative emotions and physical symptoms between partners.

“These findings illustrate a complex interplay between closeness and personal well-being in couples managing chronic illness and suggest the need for interventions that target both the benefits and potential costs of closeness,” they concluded. 

Yes, indeed, there are “benefits and potential costs” in any close relationship. It’s a contradiction that countless poets have spent centuries trying to navigate. 

Love comes at a price, but most of the time, the price is worth it. 

The Pharmacy Shuffle: Navigating the Opioid Shortage Again

By Crystal Lindell

The pain medication I take daily was completely out of stock at my pharmacy, as well as every other pharmacy near us in northern Illinois this week. 

The first replacement my doctor prescribed would cost me $529 out-of-pocket – even with a GoodRx coupon. 

Let me take you through what it’s like to navigate the morphine extended-release (ER) shortage as a pain patient who depends on this medication to function. And yes, this is the second time I’ve had to deal with the shortage in the last few months.

But this time, it was much worse. 

The whole saga really started last week, when I sent a MyChart message to my doctor’s office letting them know that I was due for a refill on Monday, March 31. They sent the refill prescription to my pharmacy on Friday, with the fill date set for Monday. 

Despite the fact that my pharmacy had this prescription in their system all weekend, they waited until 11 Monday morning to tell me that morphine ER was out of stock at their store and every other pharmacy in the area – and that there was no way to order it. 

After the pharmacy tech explained that to me, she said, “Did you want me to transfer the prescription somewhere else?”

Um, you just said it was out of stock everywhere? Where the heck would you transfer it to?

I asked her what alternatives they did have in stock, so that I could let my doctor know the best options. Because morphine ER and all of the alternatives are controlled substances, she immediately started acting like I was an armed gunman asking for details so that I could rob their narcotics safe later. 

Finding an Alternative

At that point, I realized that this situation was going to take at least the rest of the day to navigate, so I was growing impatient. I told her, “Sorry, I’m just trying to avoid having to make 17 phone calls about this, playing phone tag with you and my doctor’s office.”

She relented, and finally told me that they did have morphine instant-release (IR) available. 

I then got to work calling other local pharmacies hoping for a miracle. Unfortunately, I got the same information from all of them: Morphine ER was out of stock, they had no way to order more, and they had no idea when they might be able to get it. 

So then I called my doctor and left a message explaining the situation and that morphine instant-release was probably the best alternative. I called him 2 more times because I didn’t hear back.

Finally, the nurse called me back at 5:13 pm – just 17 minutes before the doctor was slated to leave for the day. And it was not great news. She told me that my doctor did not want to prescribe the instant-release version because he was worried it would be too strong for me. 

I suggested that he prescribe oxycodone extended-release, but that I was worried about the cost. I don’t currently have health insurance. 

My doctor sent in the oxycodone replacement at 5:28 pm, just minutes before he left for the day. 

At this point, I naively assumed that the oxycodone ER would cost around $200, which is significantly more expensive than the $60 I usually pay for morphine ER. 

Sadly, my guess of $200 was pathetically low.

My pharmacy gave me two pieces of bad news: One, they didn’t have the oxycodone in stock, but they could get it tomorrow, and two, the cash price with GoodRx would be $529. 

For some reason, the pharmacist thought this was a good time to have a conversation with me about my patient profile. He said that I needed to have my doctor prescribe a non-controlled medication for me because I only get prescriptions for controlled substances from them. That’s a red flag for the DEA, which could impact him – as if patients get to decide for their doctor what they’re prescribed.

I don’t have insurance and was on the verge of going into withdrawal without pain medication, and the pharmacist thought that was the best time to tell me that I needed to get an unnecessary medication to protect him? 

At this point, I did what any sane person would do: I started crying. 

I couldn’t afford the $529 oxycodone and now I also had the added stress of knowing that my pharmacist thinks I’m a “red flag” patient. 

I immediately called my doctor again, knowing that I was making the phone call in vain, because he was gone for the day. I was routed to the on-call service. The on-call doctor didn’t feel “comfortable” prescribing a controlled substance after hours to a patient they had never met.

By now, any patience I had was as unavailable as the morphine ER tablets were – so I used it as an opportunity to tell him that perhaps their “policy” should consider how dangerous it is to send patients into morphine withdrawal. 

He said I could go to the emergency room if it gets really bad, and I reminded him that I don’t have insurance. At that point, I accepted the fact that I will have to wait until day 2, and just hope it’s resolved then.

That night was awful. It’s not a good idea to go from 3 morphine ER tablets down to zero in one day, and I spent all night in and out of a fitful sleep, before finally deciding to get up for the day at 3 am. 

I called my doctor’s office as soon as they opened and left a message with his receptionist explaining the $529 price tag. I also let them know that I had already called additional pharmacies that morning and I was still getting the same excuse about them being out of stock with no way to order more morphine ER.

I called my doctor back again in the afternoon, because I still hadn’t gotten a response. Finally, at 3:24 pm, my doctor’s nurse called back. I had to explain this entire situation again. She gasped when I told her about the $529 price tag, said she would talk to the doctor, and call me back. 

Less than an hour later, she calls to tell me that they are sending in the prescription for morphine instant-release – the same medication they could have sent in the day before, which would have saved me from a night of unnecessary suffering. 

By that point, I was thankful that I was finally closer to getting this resolved. I call the pharmacy, they tell me they got the new script, and that they’d start working on it. It’s ready when I get there, and the price is just $52.60 – far cheaper than the oxycodone replacement. 

I Got Lucky, Other Patients May Not

The whole situation was just an awful chain of events, where I felt like I was failed by every single person in the healthcare system. Why didn’t the pharmacy tell me on Friday that my medication was out of stock? Why did my doctor’s office wait until the end of the day Monday to call me back? Why did the on-call doctor shrug me off?

I say all of this knowing that I’m one of the “lucky” ones who was actually able to get this situation resolved. Thousands of other patients are also dealing with shortages of  morphine ER and other opioids. I suspect most of them won’t get an alternative medication at all. 

My last prescription for morphine ER was manufactured by Rhodes Pharmaceuticals, which did not provide a reason for the shortage to the American Society of Health-System Pharmacists (ASHP). Neither did Major, Mallinckrodt, Sun Pharma or Teva Pharmaceuticals. The drug makers would only say the medication is on “back order.”  

You might still be able to get MS Contin, a branded version of morphine ER, but it costs more and most insurers won’t pay for it, according to the ASHP, so pharmacies don’t usually keep it in stock.

At this point, I’m genuinely wondering if generic morphine ER will ever be available again. Drug makers don’t make a lot of money selling generics and opioids come with the added risk of liability, so some manufacturers have quietly discontinued production.  

I think sometimes people believe that opioid pain medications are a want, not a need. But I need morphine ER to deal with my chronic pain. It allows me to work, shower, make dinner, clean my house, and spend time with my loved ones. Most of all, it allows me to get through the day without suicidal levels of physical pain. 

If you’re a patient trying to navigate this shortage, just know that my heart goes out to you. 

And if you're a physician or a pharmacist trying to deal with this from the other end of things, I hope you’ll treat morphine ER the same way you’d treat any other necessary, daily medication. If you wouldn’t do it to a patient who needs insulin, don’t do it to a patient who needs pain medication.

Cannabis Oil Has Long-Term Benefits for Chronic Health Conditions

By Pat Anson

Patients suffering from chronic pain and other chronic health conditions showed significant improvement in their quality of life, fatigue and sleep after taking cannabis oil over a one-year period, according to a new Australian study published in the journal PLOS One. Anxiety, depression and pain also improved during the course of the study, one of the first to demonstrate the long-term benefits of medical cannabis.

Researchers at the University of Sydney followed over 2,350 patients from across Australia who ingested cannabis oils containing both THC and CBD. Nearly two-thirds of the participants suffered from chronic musculoskeletal or neuropathic pain. Others lived with insomnia, depression, fatigue and anxiety. Participants did not get adequate relief from conventional treatments.   

Researchers found that the initial improvements in health over three months were maintained over 12 months. Because there was no control or placebo group, the improvements can’t be directly attributed to cannabis oil. But researchers noted that most of the participants stopped or reduced their use of opioid pain medication by the end of the study.

“This is promising news for patients who are not responding to conventional medicines for these conditions," said lead author Margaret-Ann Tait, a Research Manager and PhD Student at Sydney Nursing School, University of Sydney. 

The ratio of THC and CBD in the cannabis oil varied. Patients with conditions like fatigue or insomnia did better with oils that contained more THC; while those with chronic pain did better with higher ratios of CBD.

“We observed differences in the degree of improvement in fatigue, insomnia, anxiety, and depression depending on the ratio of CBD and THC in average daily MC (medical cannabis) doses. For these outcomes, average daily doses of THC-dominant MC was associated with greater odds of improvement than CBD:THC-balanced MC,” researchers said.

“Our findings suggest that people with chronic pain conditions experience better outcomes over time on lower doses of CBD when combined with smaller amounts of THC at a ratio of 10:1.”

Because this was an observational study, with different ratios of THC and CBD, researchers said they could not draw definitive conclusions about which ratios work best for each condition. The oils are made by Little Green Pharma , which funded the Quality of Life Evaluation Study (QUEST).

A 2023 survey of Australian patients with chronic illness found significant improvements in their physical and mental health after they started using medical cannabis. Most of the cannabis products in that study were oils containing CBD and/or THC.   

Sickest Patients Face Insurance Denials Over Prior Authorization

By Lauren Sausser, KFF Health News

Sheldon Ekirch spends a lot of time on hold with her health insurance company.

Sometimes, as the minutes tick by and her frustration mounts, Ekirch, 30, opens a meditation app on her phone. It was recommended by her psychologist to help with the depression associated with a stressful and painful medical disorder.

In 2023, Ekirch was diagnosed with small fiber neuropathy, a condition that makes her limbs and muscles feel as if they’re on fire. Now she takes more than a dozen prescriptions to manage chronic pain and other symptoms, including insomnia.

“I don’t feel like I am the person I was a year and a half ago,” said Ekirch, who was on the cusp of launching her law career, before getting sick. “Like, my body isn’t my own.”

Ekirch said specialists have suggested that a series of infusions made from blood plasma called intravenous immunoglobulin — IVIG, for short — could ease, or potentially eradicate, her near-constant pain.

But Ekirch’s insurance company has repeatedly denied coverage for the treatment, according to documents provided by the patient.

Patients with Ekirch’s condition don’t always respond to IVIG, but she said she deserves to try it, even though it could cost more than $100,000.

“I’m paying a lot of money for health insurance,” said Ekirch, who pays more than $600 a month in premiums. “I don’t understand why they won’t help me, why my life means so little to them.”

SHELDON EKIRCH

For patient advocates and health economists, cases like Ekirch’s illustrate why prior authorization has become such a chronic pain point for patients and doctors. For 50 years, insurers have employed prior authorization, they say, to reduce wasteful health care spending, prevent unnecessary treatment, and guard against potential harm.

The practice differs by insurance company and plan, but the rules often require patients or their doctors to request permission from the patient’s health insurance company before proceeding with a drug, treatment, or medical procedure.

The insurance industry provides little information about how often prior authorization is used. Transparency requirements established by the federal government to shed light on the use of prior authorization by private insurers haven’t been broadly enforced, said Justin Lo, a senior researcher for the Program on Patient and Consumer Protections at KFF, a health information nonprofit that includes KFF Health News.

Yet it’s widely acknowledged that prior authorization tends to disproportionately impact some of the sickest people who need the most expensive care. And despite bipartisan support to reform the system, as well as recent attempts by health insurance companies to ease the burden for patients and doctors, some tactics have met skepticism.

Some insurers’ efforts to improve prior authorization practices aren’t as helpful as they would seem, said Judson Ivy, CEO of Ensemble Health Partners, a revenue cycle management company.

“When you really dive deep,” he said, these improvements don’t seem to touch the services and procedures, such as CT scans, that get caught up in prior authorization so frequently. “When we started looking into it,” he said, “it was almost a PR stunt.”

The ‘Tipping Point’

When Arman Shahriar’s father was diagnosed with follicular lymphoma in 2023, his father’s oncologist ordered a whole-body PET scan to determine the cancer’s stage. The scan was denied by a company called EviCore by Evernorth, a Cigna subsidiary that makes prior authorization decisions.

Shahriar, an internal medicine resident, said he spent hours on the phone with his father’s insurer, arguing that the latest medical guidelines supported the scan. The imaging request was eventually approved. But his father’s scan was delayed several weeks — and multiple appointments were scheduled, then canceled during the time-consuming process — while the family feared the cancer would continue to spread.

EviCore by Evernorth spokesperson Madeline Ziomek wrote in an emailed statement that incomplete clinical information provided by physicians is a leading cause of such denials. The company is “actively developing new ways to make the submission process simpler and faster for physicians,” Ziomek said.

In the meantime, Shahriar, who often struggles to navigate prior authorization for his patients, accused the confusing system of “artificially creating problems in people’s lives” at the wrong time.

“If families with physicians are struggling through this, how do other people navigate it? And the short answer is, they can’t,” said Shahriar, who wrote about his father’s case in an essay published last year by JAMA Oncology. “We’re kind of reaching a tipping point where we’re realizing, collectively, something needs to be done.”

The fatal shooting of UnitedHealthcare CEO Brian Thompson on a New York City sidewalk in December prompted an outpouring of grief among those who knew him, but it also became a platform for public outrage about the methods insurance companies use to deny treatment.

An Emerson College poll conducted in mid-December found 41% of 18- to 29-year-olds thought the actions of Thompson’s killer were at least somewhat acceptable. In a NORC survey from the University of Chicago conducted in December, two-thirds of respondents indicated that insurance company profits, and their denials for health care coverage, contributed “a great deal/moderate amount” to the killing.

Instagram accounts established in support of Luigi Mangione, the 26-year-old Maryland suspect accused of murder and terrorism, have attracted thousands of followers.

“The past several weeks have further challenged us to even more intensely listen to the public narrative about our industry,” Cigna Group CEO David Cordani said during an earnings call on Jan. 30. Cigna is focused on “making prior authorizations faster and simpler,” he added.

The first Trump administration and the Biden administration put forth policies designed to improve prior authorization for some patients by mandating that insurers set up electronic systems and shortening the time companies may take to issue decisions, among other fixes.

Hundreds of House Democrats and Republicans signed on to co-sponsor a bill last year that would establish new prior authorization rules for Medicare Advantage plans. In January, Republican congressman Jefferson Van Drew of New Jersey introduced a federal bill to abolish the use of prior authorization altogether.

Meanwhile, many states have passed legislation to regulate the use of prior authorization. Some laws require insurers to publish data about prior authorization denials with the intention of making a confusing system more transparent.

Reform bills are under consideration by state legislatures in Hawaii, Montana, and elsewhere. A bill in Virginia approved by the governor March 18 takes effect July 1. Other states, including Texas, have established “gold card” programs that ease prior authorization requirements for some physicians by allowing doctors with a track record of approvals to bypass the rules.

No one from AHIP, an insurance industry lobbying group formerly known as America’s Health Insurance Plans, was available to be interviewed on the record about proposed prior authorization legislation for this article.

But changes wouldn’t guarantee that the most vulnerable patients would be spared from future insurance denials or the complex appeals process set up by insurers. Some doctors and advocates for patients are skeptical that prior authorization can be fixed as long as insurers are accountable to shareholders.

Kindyl Boyer, director of advocacy for the nonprofit Infusion Access Foundation, remains hopeful the system can be improved but likened some efforts to playing “Whac-A-Mole.” Ultimately, insurance companies are “going to find a different way to make more money,” she said.

‘Unified Anger’

In the weeks following Thompson’s killing, UnitedHealthcare was trying to refute an onslaught of what it called “highly inaccurate and grossly misleading information” about its practices when another incident landed the company back in the spotlight.

On Jan. 7, Elisabeth Potter, a breast reconstruction surgeon in Austin, Texas, posted a video on social media criticizing the company for questioning whether one of her patients who had been diagnosed with breast cancer and was undergoing surgery that day needed to be admitted as an inpatient.

The video amassed millions of views.

In the days following her post, UnitedHealthcare hired a high-profile law firm to demand a correction and public apology from Potter. In an interview with KFF Health News, Potter would not discuss details about the dispute, but she stood by what she said in her original video.

“I told the truth,” Potter said.

The facts of the incident remain in dispute. But the level of attention it received online illustrates how frustrated and vocal many people have become about insurance company tactics since Thompson’s killing, said Matthew Zachary, a former cancer patient and the host of “Out of Patients,” a podcast that aims to amplify the experiences of patients.

For years, doctors and patients have taken to social media to shame health insurers into approving treatment. But in recent months, Zachary said, “horror stories” about prior authorization shared widely online have created “unified anger.”

“Most people thought they were alone in the victimization,” Zachary said. “Now they know they’re not.”

Data published in January by KFF found that prior authorization is particularly burdensome for patients covered by Medicare Advantage plans. In 2023, virtually all Medicare Advantage enrollees were covered by plans that required prior authorization, while people enrolled in traditional Medicare were much less likely to encounter it, said Jeannie Fuglesten Biniek, an associate director at KFF’s Program on Medicare Policy.

Furthermore, she said, Medicare Advantage enrollees were more likely to face prior authorization for higher-cost services, including inpatient hospital stays, skilled nursing facility stays, and chemotherapy.

But Neil Parikh, national chief medical officer for medical management at UnitedHealthcare, explained prior authorization rules apply to fewer than 2% of the claims the company pays. He added that “99% of the time” UnitedHealthcare members don’t need prior authorization or requests are approved “very, very quickly.”

Recently, he said, a team at UnitedHealthcare was reviewing a prior authorization request for an orthopedic procedure when they discovered the surgeon planned to operate on the wrong side of the patient’s body. UnitedHealthcare caught the mistake in time, he recounted.

“This is a real-life example of why prior authorization can really help,” Parikh said.

Even so, he said, UnitedHealthcare aims to make the process less burdensome by removing prior authorization requirements for some services, rendering instant decisions for certain requests, and establishing a national gold card program, among other refinements. Cigna also announced changes designed to improve prior authorization in the months since Thompson’s killing.

“Brian was an incredible friend and colleague to many, many of us, and we are deeply saddened by his passing,” Parikh said. “It’s truly a sad occasion.”

The Final Denial

During the summer of 2023, Ekirch was working full time and preparing to take the bar exam when she noticed numbness and tingling in her arms and legs. Eventually, she started experiencing a burning sensation throughout her body.

That fall, a Richmond-area neurologist said her symptoms were consistent with small fiber neuropathy, and, in early 2024, a rheumatologist recommended IVIG to ease her pain. Since then, other specialists, including neurologists at the University of Virginia and Virginia Commonwealth University, have said she may benefit from the same treatment.

There’s no guarantee it will work. A randomized controlled trial published in 2021 found pain levels in patients who received IVIG weren’t significantly different from the placebo group, while an older study found patients responded “remarkably well.”

“It’s hard because I look at my peers from law school and high school — they’re having families, excelling in their career, living their life. And most days I am just struggling, just to get out of bed,” said Ekirch, frustrated that Anthem continues to deny her claim.

In a prepared statement, Kersha Cartwright, a spokesperson for Anthem’s parent company, Elevance Health, said Ekirch’s request for IVIG treatment was denied “because it did not meet the established medical criteria for effectiveness in treating small fiber neuropathy.”

On Feb. 17, her treatment was denied by Anthem for the final time. Ekirch said her patient advocate, a nurse who works for Anthem, suggested she reach out to the drug manufacturer about patient charity programs.

“This is absolutely crazy,” Ekirch said. “This is someone from Anthem telling me to plead with a pharmacy company to give me this drug when Anthem should be covering it.”

Her only hope now lies with the Virginia State Corporation Commission Bureau of Insurance, a state agency that resolves prior authorization disputes between patients and health insurance companies. She found out through a Facebook group for patients with small fiber neuropathy that the Bureau of Insurance has overturned an IVIG denial before. In late March, Ekirch was anxiously waiting to hear the agency’s decision about her case.

“I don’t want to get my hopes up too much, though,” she said. “I feel like this entire process, I’ve been let down by it.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

HHS Cuts Signal Seismic Shift in Public Health Policy

By Simon Haeder

Department of Health and Human Services Secretary Robert F. Kennedy, Jr. recently announced plans to dramatically transform the department. HHS is the umbrella agency responsible for pandemic preparedness, biomedical research, food safety and many other health-related activities.

In a video posted last week, Kennedy said the cuts and reorganization to HHS aim to “streamline our agency” and “radically improve our quality of service” by eliminating rampant waste and inefficiency. “No American is going to be left behind,” the health secretary told the nation.

As a scholar of U.S. health and public health policy, I have written about administrative burdens that prevent many Americans from accessing benefits to which they are entitled, including those provided by HHS, like Medicaid.

Few experts would deny that the federal bureaucracy can be inefficient and siloed. This includes HHS, and calls to restructure the agency are nothing new

Combined with previous reductions, these cuts may achieve some limited short-term savings. However, the proposed changes dramatically alter U.S. health policy and research, and they may endanger important benefits and protections for many Americans. They may also have severe consequences for scientific progress. And as some policy experts have suggested, the poorly targeted cuts may increase inefficiencies and waste down the line.

What HHS Does

HHS is tasked with providing a variety of public health and social services as well as fostering scientific advancement.

Originally established as the Department of Health, Education, and Welfare in 1953, HHS has seen substantial growth and transformation over time. Today, HHS is home to 28 divisions. Some of these are well known to many Americans, such as the National Institutes of Health, the Food and Drug Administration and the Centers for Disease Control and Prevention. Others, such as the Center for Faith-Based and Neighborhood Partnerships and the Administration for Community Living, may fly under the radar for most people.

HHS oversees Medicare, through which 68 million Americans, primarily adults age 65 and older, receive health insurance benefits. Richard Bailey/Corbis Documentary via Getty Images

With an annual budget of roughly US$1.8 trillion, HHS is one of the largest federal spenders, accounting for more than 1 in 5 dollars of the federal budget.

Under the Biden administration, HHS’s budget increased by almost 40%, with a 17% increase in staffing. However, 85% of that money is spent on 79 million Medicaid and 68 million Medicare beneficiaries. Put differently, most of HHS’ spending goes directly to many Americans in the form of health benefits.

Layoffs Affect 25% of HHS Workforce

From a policy perspective, the changes initiated at HHS by the second-term Trump administration are far-reaching. They involve both staffing cuts and substantial reorganization.

Prior to the March 27 announcement, the administration had already cut thousands of positions from HHS by letting go probationary employees and offering buyouts for employees to voluntarily leave.

Now, HHS is slated to lose another 10,000 workers. The latest cuts focus most heavily on a handful of agencies. The FDA will lose an additional 3,500 employees, and the NIH will lose 1,200. The CDC, where cuts are steepest, will lose 2,400 positions.

In all, the moves will reduce the HHS workforce by about 25%, from more than 82,000 to 62,000. These changes will provide savings of about $1.8 billion, or 0.1% of the HHS budget.

Along with these cuts comes a major reorganization that will eliminate 13 out of 28 offices and agencies, close five of the 10 regional offices, reshuffle existing divisions and establish a new division called the Administration for a Healthy America.

In his latest message, Kennedy noted that this HHS transformation would return the agency to its core mission: to “enhance the health and well-being of all Americans”. He also announced his intention to refocus HHS on his Make America Healthy Again priorities, which involve reducing chronic illness “by focusing on safe, wholesome food, clean water and the elimination of environmental toxins.”

‘Painful Period’ for HHS

Kennedy has said the HHS overhaul will not affect services to Americans. Given the magnitude of the cuts, this seems unlikely.

HHS reaches into the lives of all Americans. Many have family members on Medicaid or Medicare, or know individuals with disabilities or those dealing with substance use disorder. Disasters may strike anywhere. Bird flu and measles outbreaks are unfolding in many parts of the country. Everyone relies on access to safe foods, drugs and vaccines.

The plan to restructure HHS will trim its budget by 0.1%.

In his announcement, the health secretary highlighted cuts to HHS support functions, such as information technology and human resources, as a way to reduce redundancies and inefficiencies. But scaling down and reorganizing these capacities will inevitably have implications for how well HHS employees will be able to fulfill their duties – at least temporarily. Kennedy acknowledged this as a “painful period” for HHS.

However, large-scale reductions and reorganizations inevitably lead to more systemic disruptions, delays and denials. It seems implausible that Americans seeking access to health care, help with HIV prevention or early education benefits such as Head Start, which are also administered by HHS, will not be affected. This is particularly the case when conceived rapidly and without transparent long-term planning.

These new cuts are also further exacerbated by the administration’s previous slashes to public health funding for state and local governments. Given the crucial functions of HHS – from health coverage for vulnerable populations to pandemic preparedness and response – the American Public Health Association predicts the cuts will result in a rise in rates of disease and death.

Already, previous cuts at the FDA – the agency responsible for safe foods and drugs – have led to delays in product reviews.

Overall, the likelihood of increasing access challenges for people seeking services or support as well as fewer protections and longer wait times seems high.

Fewer Benefits and Services

The HHS restructuring should be viewed in a broader context. Since coming to office, the Trump administration has aggressively sought to reshape the U.S. public health agenda. This has included vast cuts to research funding as well as funding for state and local governments. The most recent cuts at HHS fit into the mold of rolling back protections and reshaping science.

The Trump administration has already announced plans to curtail the Affordable Care Act and roll back regulations that address everything from clean water to safe vaccines. State programs focused on health disparities have also been targeted.

HHS-funded research has also been scaled back dramatically, with a long list of projects terminated in research areas touching on health disparities, women’s and LGBTQ-related health issues, COVID-19 and long COVID, vaccine hesitancy and more.

The HHS reorganization also revamps two bodies within HHS, the Office of the Assistant Secretary for Planning and Evaluation and the Agency for Healthcare Research and Quality, that are instrumental in improving U.S. health care and providing policy research. This change further diminishes the likelihood that health policy will be based on scientific evidence and raises the risk for more politicized decision-making about health.

More cuts are likely still to come. Medicaid, the program providing health coverage for low-income Americans, will be a particular target. The House of Representatives passed a budget resolution on Feb. 25 that allows up to $880 billion in cuts to the program.

All told, plans already announced and those expected to emerge in the future dramatically alter U.S. health policy and roll back substantial protections for Americans.

Regulation has emerged as the most prolific source of policymaking over the last five decades, particularly for health policy. Given its vast responsibilities, HHS is one of the federal government’s most prolific regulators. Vast cuts to the HHS workforce will likely curtail this capability, resulting in fewer regulatory protections for Americans.

At the same time, with fewer experienced administrators on staff, industry influence over regulatory decisions will likely only grow stronger. HHS will simply lack the substance and procedural expertise to act independently. More industry influence and fewer independent regulators to counter it will also further reduce attention to disparities and underserved populations.

Ultimately, the Trump administration’s efforts may lead to a vastly different federal health policy – with fewer benefits, services and protections – than what Americans have become accustomed to in modern times.

Simon F. Haeder, PhD, is an Associate Professor of Public Health in the Department of Health Policy & Management in the School of Public Health at Texas A&M University. 

Dr. Haeder studies the politics and policies surrounding health access issues, with a particular focus on health access for vulnerable populations, the impact of provider networks on health access, and school-based health access. 

This article was originally appeared in The Conversation and is republished with permission.

Pain Makes Young Adults More Likely to Mix Cannabis with Alcohol

By Crystal Lindell

A new study reveals that being in pain as a young adult makes you more likely to mix cannabis and alcohol. 

The research, published in the journal Alcohol, looked at 18 to 24 year olds. They found that those with moderate to severe pain were 1.4 times more likely to engage in the co-use of alcohol and cannabis over the next four years, compared to those with no pain. 

The Binghamton University researchers say this is the first study to examine pain as a predictor for co-using alcohol and cannabis. 

Previous research has shown that young adults who mix alcohol and cannabis are more likely to engage in impaired driving, risky sexual behavior, and/or experience mental health problems. 

But that begs the question, which causes which? 

I don’t think we should assume that using cannabis and alcohol together causes mental health issues. Perhaps it is the stress and anxiety of young adulthood – and poorly treated pain – that cause people to seek relief with things like alcohol and cannabis.

Previous studies have shown that about two-thirds (67%) of young adults in the U.S. reported pain in the past six-months, and more than 2 million of them had chronic pain. 

Physical pain in young adulthood can have long-lasting consequences. 

"Pain is of particular concern during emerging adulthood because it directly impacts developmental milestones across multiple domains, and emerging adults with chronic pain report greater isolation from their peers, fewer educational and occupational opportunities, greater anxiety and depression, and a poorer overall quality of life," the authors write. 

All of this really highlights why it’s so important that we fully treat pain in young adults – and really, in everyone who suffers from it. 

Unfortunately, that’s not the framing the authors chose to go with in their paper. Instead, they write that “pain is a unique risk factor for substance use.”

The choice to use “risk factor” in that sentence speaks volumes, although I am glad that they then used “substance use” as opposed to the more judgemental “substance abuse.”

Because that’s the thing, using a substance to treat something is not inherently bad. People use ibuprofen to treat headaches. But we don’t have research papers claiming that “headaches are a risk factor for Advil use.” Or even “having diabetes is a risk factor for insulin use.” 

Like yeah, you think? People use medications that treat their ailment in order to treat their ailment. 

Pain is definitely an aliment – and cannabis and alcohol are substances that do indeed relieve pain. The only reason anyone believes otherwise is because of government framing. 

We have drastically reduced the amount of opioids prescribed, but that doesn’t mean we have drastically reduced the amount of pain that people endure. It’s only natural that people will seek out alternatives. Younger people tend to have a more difficult time convincing doctors to treat their pain, meaning they are more likely to be left to fend for themselves. 

Alcohol and cannabis may not be the best choices for pain relief, but they may be the only ones available.

People in pain — at any age — will always look for ways to alleviate that pain. And the more options people in pain have, the more likely it is that they’ll find what works best for their body and their circumstances, while causing the least amount of negative side effects. 

If their only effective option is alcohol mixed with cannabis, then that’s what they’ll use. If the government and medical community don’t like that, then they should give them more options. 

My Use of Opioids Is None of Your Business

By Neen Monty

It seems like everyone these days has an unsolicited opinion about my pain management. Physical therapists, pharmacists, even my dentist has decided they need to weigh in on my opioid use.

Why do health care professionals who do not specialise in pain management feel entitled to comment on the way I manage my severe, long-standing pain? They clearly know nothing about opioids, have not read the studies, and are getting their knowledge from media headlines. If they actually read the studies, they wouldn’t be expressing these ignorant opinions.

But even so, it’s none of their business. If they are not treating my pain, why do they feel entitled to lecture me on a treatment plan that is well outside their expertise?

My rheumatologist doesn’t comment on my gastroenterologist’s treatment plan. My neurologist has zero interest in the way my immunologist is managing my symptoms. So why do health care professionals feel the need to comment on my use of opioids for pain relief?

For years, my pain was well controlled under the guidance of my GP — whom, I might add, is more than capable of managing pain. I never needed a pain specialist. I never needed to jump through ridiculous hoops or prove that my pain was “real enough” to deserve relief. And yet, thanks to the manufactured opioid crisis here in Australia, I was forced into a system that treats pain patients like criminals.

Let’s be clear: I am not an addict. I am a person with severe, incurable and excruciatingly painful diseases. Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) is a progressive neurological disease that attacks my nerves. Refractory rheumatoid arthritis means my immune system is at war with my joints – all of them - and it’s winning.

These are not minor aches and pains. This is not pain that comes and goes. This is constant, severe pain. Pain when I’m at rest and even more pain when I move.  

These are not conditions that can be fixed with a little physio, deep breathing, or positive thinking. They are devastating, life-altering diseases, and pain relief is essential to my ability to function.

And yet, here we are. Every healthcare professional I encounter suddenly thinks my pain medication is their business.

My dentist, who is supposed to focus on my teeth, thinks it’s appropriate to lecture me on opioids.

My physiotherapist, whose job is to help me maintain muscle strength and mass, feels the need to moralise about my use of opioids. He is an expert in physiology and movement science, but knows nothing about pharmacology. Yet he believes that he does. And he's happy to tell me so.

Pharmacists, who definitely should know better, jump on the bandwagon with their judgmental takes. Yes, I have a supply of naloxone, even though it’s the biggest waste of money the government has ever been conned into spending by addiction researchers. I am at zero risk of needing it.

And no, I do not want information about how to taper my pain medicine. I actually need my pain medicine. I take it because I live with neuropathic and nociceptive chronic pain. You should try it sometime. I don’t think you’d enjoy it, but you’d be a better clinician. And person.

All of this unsolicited advice amounts to little more than bullying. Just the mention of an opioid turns some health care professionals into the high school bully. Do you want my lunch money as well?

What is this obsession with controlling other people’s pain relief? Why do you even have an opinion, when it is far outside of your area of practice? How can you possibly think it’s appropriate for you to judge how I treat my disease or my pain, when you met me two minutes ago?

Most of all, where is your empathy? Your compassion? Your human decency?

Lecturing and hectoring me is not compassionate, person-centred care.

Do you have an opinion on whether I take methotrexate or baricitinib for my rheumatoid arthritis? Does it matter, to you, which cDMARD or bDMARD I am taking? You’ve never heard of them, have you? They rarely make media headlines. Yet they are both riskier medications than opioids, and are more likely to cause serious adverse events. Yet you don’t care about those at all.

Do you care about my IVIG infusions? It’s extremely expensive medication. Unlike opioids, which are very cheap.

What about my steroid dose? You should care about that. All health care professionals know that high dose steroids, taken long term, are very dangerous. They often end up killing people. But because ignorant medical practitioners have taken my opioids away, I have been forced to live on high dose steroids. And all the side effects they bring.

But that’s fine with you. You don’t care about my steroid use. Only my poor endocrinologist does. Lovely gentleman. I can tell he truly cares about me as a patient. It shows in the way he treats me. With calm, gentle respect. He also stays in his lane. The only comment he has made about my opioid use is something akin to “I’m sorry you’re in so much pain.”

That’s a good doctor. After my first appointment with him, I went to my car and cried for 15 minutes straight. I’m not used to receiving that kind of compassion and empathy.

I normally get lectures. Unsolicited advice. And scare tactics: “Those drugs will kill you, you know!”

Or disgusted disbelief: “The pain can’t be that bad!”

Or, very commonly, abandonment: “You’re just going to have to learn to live with it.”

But why should I learn to live with pain that is easily treatable? Because you refuse to read the science? Because you like to get your medical knowledge from politicians, corrupt psychiatrists on the take, and researchers who misreport their own data to keep the grant money flowing?

Yeah, I know. At first, I thought all that was a conspiracy theory – no one would be so evil as to harm people who live with horrifically painful diseases just to further their own career, right? Of course not. No one would do… oh wait. Yes, they would.

Opioids are not for everyone. And thankfully, most people will never experience the kind of pain that requires around-the-clock opioids.

But when opioids are the only thing that reduces pain enough so that a person can survive and have a life, then opioids should be given. And in doses that actually relieve the pain, not a dose that some regulator or politician decided would be enough for everyone. Severe pain is a medical emergency. It does not matter if that pain is acute or chronic.

But let’s go back a step. I am in constant, severe pain. My nerves are being destroyed by my immune system, as are my joints. This is a documented and very painful disease process. Yet there is not an ounce of empathy. Not anymore, anyway.

Back in 2011, I went to a GP in absolute distress. I could not cope with the pain anymore and was crawling along the floor to get to the bathroom. The GP was compassionate. He knew that severe RA is a horrifically painful disease. He prescribed oxycodone and I got my life back.

And now? Health care professionals only have one thing to say: “Stop taking those opioids!”

It’s clear that these clinicians do not believe my pain is severe. It’s clear they don’t believe anything warrants long term opioid use. It’s clear that some think I only want opioids to get high.

Most clear of all is that they feel an entitlement to lecture me about it. When they know nothing about my pain.

The stigma created by the manufactured opioid crisis has turned us into the type of patients no doctor wants to treat. We are seen as liabilities. Nuisances. Whiners. Complainers. Time wasters. We’re seen as problems to be managed, rather than human beings in desperate need of help.

“Heartsink patients.” Are you familiar with that term? Google it. Heartsink patients are said to “exasperate, defeat, and overwhelm their doctors.”

I don’t fit that profile. Not even close. Very few people do. The profile was created so that doctors can feel they have the right to save the patient from themselves. Every single healthcare professional seems to think they have the right to weigh in, to judge and to lecture pain patients.

Here’s a radical idea: Mind your own business. Even better, educate yourself.

Read some recent science. Some peer reviewed science. Even read the studies that are referenced in the opioid prescribing guidelines. I promise you, they don’t say what you think they say.

Unless you are my GP or the prescribing doctor actively involved in my pain management, my opioid pain medication is not your concern. Yes, I need to tell you about it, in case you want to prescribe something that interacts with opioids. But that does not give you the right to judge me.

Pain is not a moral failing.

Taking opioids to manage pain is not a character flaw.

And it is none of your business.

Neen Monty is a writer and patient advocate in Australia who is dedicated to challenging misinformation and promoting access to safe, effective pain relief. Drawing on lived experience and scientific research, Neen has created a website for Pain Patient Advocacy Australia that is full of evidence that opioids can be safe and effective, even when taken long term. You can also subscribe to her free newsletter on Substack, “Arthritic Chick on Chronic Pain.”

Nearly All Hemp Products Could Get You High

uy Crystal Lindell

The promise of legalized hemp products was always that you couldn’t high on them, and they would be more regulated and thus safer for consumers. But a new white paper reveals that most hemp products contain intoxicants like THC, synthetic cannabinoids, kratom or even hallucinogenic mushrooms.

Hemp products have only been sold legally in the United States since 2021, the result of hemp being legalized as part of the 2018 Farm Bill. The thinking at the time was that hemp contained such minuscule amounts of THC that farmers could grow hemp again as a cash crop to make things like rope, fuel and horse feed. 

But it didn’t take long for the cannabis industry to figure out how to tweak the chemical composition of hemp to make delta-8 tetrahydrocannabinol (THC) and other potent synthetic cannabinoids, which you can get high on.

The white paper, called The Great Hemp Hoax, examined the composition and potency of hemp products sold in two southern California counties, focusing on chemically synthesized cannabinoids. The results reveal the hemp market has evolved far beyond what lawmakers and regulators intended. 

In an analysis of 104 hemp-based products from 68 brands, researchers found that 95 percent contain synthetic cannabinoids, which are illegal in California. These compounds are often far more potent than naturally occurring THC.  

More than half of the tested products exceeded the federal 0.3 percent THC limit, technically classifying them as cannabis rather than hemp under federal law. In fact, researchers found that many of these products vastly exceeded THC potency limits imposed on regulated cannabis products. 

Some hemp gummies contained up to 325 milligrams of synthetic THC per serving — which is way over the 10mg cap in California’s legal market.

You could also get high on hemp-derived vape products, which had an average THC equivalency level 268% above the state’s threshold for adult-use cannabis.

Some hemp products — such as Cheech & Chong’s “Kosmic Chews” — even contain psychoactive additives like kratom, while others include hallucinogenic mushrooms.

THE GREAT HEMP HOAX

“Much of what’s being sold as ‘hemp’ today isn’t hemp at all — it’s a cocktail of synthetic intoxicants and illicit THC masquerading as a natural, legal product. It's essentially the ultra-processed junk food of cannabis, but far more dangerous," said Tiffany Devitt, Director of Regulatory Affairs at Groundwork Holdings, which helped establish the cannabis industry in California and is trying to protect it from hemp competitors. 

"These companies aren't just skirting regulations – they're putting consumers at serious risk with designer drugs that look a whole lot more like ‘Spice’ than natural hemp."

Devitt and other authors of the white paper believe the contamination is not accidental. They said that filtering out or reducing the amount of delta-8 or delta-9 THC in hemp products is inefficient and cost-prohibitive, incentivizing companies to not do it.

“Because of these inefficiencies, most so-called ‘hemp-derived’ THC products are, in reality, synthetic cannabis — reminiscent of illegal products like ‘Spice’ that flooded California a decade ago,” they wrote. 

The lack of oversight also results in tax evasion. Over 90% of the hemp products analyzed were sold without collecting California’s sales tax, and none of the vendors paid the state’s cannabis excise tax. 

“The failure to ensure tax accountability allows unregulated ‘hemp’ products to undercut the legal cannabis market while depriving the state of revenue meant for public health, environmental mitigation, and enforcement,” the authors concluded. 

The white paper calls for all hemp products containing THC to be regulated as cannabis within California, to protect consumers and workers.

“These illicit operations aren’t just dangerous — they’re undercutting California’s regulated cannabis businesses and workers,” said Kristin Heidelbach, Legislative Director of the United Food and Commercial Workers Union, which helped pay for the white paper.

“While licensed cannabis businesses provide good union jobs and comply with strict labor standards, many synthetic ‘hemp’ producers manufacture out-of-state or import from overseas, dodging California’s labor laws and tax obligations.”

This isn’t just a California issue. A recent study found that nationwide sales of hemp products reached $2.8 billion in 2023. They are legally sold to minors in many U.S. states, even in those where cannabis is illegal. In 2023, about 11% of 12th graders said they had used hemp products containing Delta-8 THC.