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Dr Norman Marcus
The safest, most effective, and often least expensive treatments for muscular pain are the hardest to access. Because insurance policies are built around a vision of pain care that no longer reflects modern science.
Today, millions of Americans navigate a system that financially favors procedural interventions over conservative care, diagnostic imaging over functional examination, and short-term symptom control over long-term recovery strategies. This imbalance is particularly evident in the management of muscle-related pain.
Muscle pain is one of the most common contributors to chronic back, neck, and various joint-related pain. Yet interventions that address muscle dysfunction such as targeted physical therapy, manual treatments, myofascial release, or various muscle stimulation treatments are often under-reimbursed, inconsistently covered, or restricted through complex pre-authorization requirements. Meanwhile, high-cost procedures like MRIs, injections, and surgeries are routinely approved, even when evidence suggests that common pain syndromes, often muscle-driven, would respond better to conservative muscular treatment.
This misalignment is not simply a bureaucratic inconvenience; it represents a structural failure with far-reaching consequences.
Insurance policies influence which treatments clinicians offer and which options patients consider. When muscular treatments receive minimal reimbursement, providers are forced to choose between offering care they cannot afford to deliver or defaulting to better-reimbursed interventions.
These skewed incentives result in predictable outcomes:
This system fails because reimbursement structures restrict clinicians choice of evidence-based pathways.
Chronic pain costs the United States hundreds of billions of dollars annually. But a significant portion of that expenditure stems from inefficient care unnecessary MRIs, ineffective medications, repeat procedures, and surgeries that offer limited benefit.
Consider a patient with low back pain whose true underlying issue is a dysfunctional muscle. If insurers do not cover muscle-focused evaluations or discourage physical therapy through low reimbursement rates, the patient may be channeled instead toward imaging and injections. When these fail, surgery may follow.
This entire trajectory is costly, invasive, and often avoidable flows from an insurance framework that prioritizes structural explanations over muscular ones.
The economic argument for reform is to cover the right care early, and you prevent costly interventions later.
Reforming insurance policies for muscle pain is achievable. Several principles can guide change:
Clinicians should be appropriately compensated for functional evaluations that include muscular analysis.
Physical therapy, manual therapy, and innovative diagnostic tools should be accessible without excessive administrative barriers.
Insurers should reward interventions supported by outcomes, not tradition.
Muscle-based treatments should not be subject to more hurdles than high-cost procedures that carry greater risks.
Historical experience with overidentification and treatment of muscle generated pain soured the insurance community on covering the treatment. Formal education and dissemination of accepted guidelines for diagnosis and treatment of soft issue pain will improve outcomes if done based on uniformly adhered to evidence based standards of care - aligning perfectly with modern principles of cost-effective care.
Science has advanced. The evidence continues to grow. Millions of patients are living with chronic pain that could be treated more effectively and economically. But until insurance policies align with the reality of muscle-based pain, the system will continue to produce unnecessary suffering and unnecessary costs.
This is a call to action - for policymakers, insurers, clinicians, and advocates.
Reforming insurance coverage is not merely an administrative adjustment. It is an ethical imperative and a public health opportunity. When insurance policies finally recognize muscle pain as a legitimate, diagnosable, and treatable condition, the impact will be profound: fewer surgeries, lower costs, better outcomes, and a healthcare system that finally reflects scientific truth.
The pathway is clear. What remains is the collective will to act.
