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National Employer Group CMO on CAM/IM and Agreements for a New Employer-Practitioner Relationship PDF Print E-mail
Written by John Weeks   

National Employer Group CMO on CAM/IM and Agreements Underlying a New Employer-Practitioner Relationship 

Summary:  Alan Zwerner, JD, MD, the chief medical officer for the Institute for Health and Productivity Management (IHPM), has a positive view of complementary and integrative providers (CAM/IM) going back to a health plan experiment with chiropractic in the early 1990s that found "the same or better results with much less cost and more satisfaction." CAM/IM providers, he believes, "tend to care more about functionality" in outcomes with their patients. But are you aligned with the 16 characteristics of today's health care that Zwerner believes are a foundation for a "new contract" between providers and employers. He proposes them as a basis for healthcare reform? How does CAM-IM fit in?
Send your comments to johnweeks@theintegratorblog/com
for inclusion in a future Your Comments article.

To progressive corporate designers of healthcare benefits,
the human being as employee is transformed, via a new paradigm of thinking, from a "cost center" to an "investment." Instead of focusing on limiting the cost of medical coverage, the employer plans based on the economic values that can accrue to the corporation through investment in developing healthy and productive employees.

Image This is a paradigm shift advocated by the Institute for Health and Productivity Management (IHPM). The shift is from a reductive perspective to one that is more wholistic or "global" as is the typical framing. Returns to the employer may be measured in greater functionality and increased productivity, less disability, fewer adverse effects and less employee turnover, as well as decreased medical costs.

Such a shift in thinking about medicine requires a "new contract with physicians," according to Alan Zwerner, MD, JD, IHPM's chief medical officer. (See Integrator exploration of Zwerner's initial column here.) Zwerner posits a list of agreements about our current healthcare which he believes must underlie this new "contract."

A Paradigm Shift
for Employers

The paradigm shift

in employer thinking
is from a reductive
focus on limiting costs
to a more wholistic
or "global" view that
focuses on the
economic value of
healthy employees.
But what if the focus is not only on conventional physicians, but also on those from the distinct natural healthcare disciplines, and integrative medicine MDs. Is such a shift required?

Healthplan Trial with Hired Chiropractors Opens His Thinking

Zwerner responds directly, from a personal perspective: "I have always felt that CAM and integrative medicine people tend to care more about functionality."

Zwerner recalled his "touch point" with these fields. In the early 1990s, he was a senior medical director with the $2-billion staff-model HMO FHP (later purchased by Pacificare). He helped manage the services of 350 fulltime (FTE), employed medical doctors. He recalls:
"We had a lot of trouble with low back cost and satisfaction with our orthopedic care. We started using 6-8 FTE chiropractors. We found the same or better results with much less cost and more satisfaction."
Zwerner subsequently worked as CMO for HealthNet, which contracted with American Specialty Health (ASH), the dominant CAM management company, for complementary health benefits. Zwerner ended up speaking at a 1998 meeting at Stanford University which ASH sponsored and "ended up on CBS Evening News."

Alan Zwerner, JD, MD
Zwerner says that "mainstream CAM has always interested me." He reflects: "Much of what we do in Western medicine has no evidentiary basis. There's a lot of hocus pocus. CAM has one thing going for it that allopathic medicine doesn't, and that is that some (CAM) things have been around longer and may have more value. I'm all for studying how to best integrate these services."

Toward a New Contract with Complementary and Alternative Practitioners

Zwerner had some specific suggestions for the complementary and integrative medicine communities. He first deferred, saying he did not wish to be presumptuous, then stated:

  • "Data talks. Engage and encourage others to engage in studies that will quantify the benefits of the approaches."

  • "Don't be afraid of functional outcomes. Allopathic medicine usually doesn't have outcomes evidence either. This is a level playing field. We're all playing on a field of ignorance."

"Don't be afraid of

functional outcomes.
Allopathic medicine
usually doesn't

have outcomes
evidence either.

"This is a level
playing field.

all playing
on a
field of

- Alan Zwerner, MD, JD

Zwerner urges educational institutions and associations involved with CAM and IM fields to push this focus on generating data on functional outcomes.

Changing the Culture of the Culture
- Suggested Basic Agreements

Zwerner's suggestion that CAM/IM organizations add to, or reframe, their institutional priorities is not any different than what Zwerner and IHPM are working to do with the paradigm shift they are promoting regarding employee health. Says Zwerner: "We are trying to change the culture of the organization." Then he pauses and adds: " ... to change the culture of the culture."

Zwerner believes that it is critical that the organization's "C-Suite" - referring to the CEO, CFO, CMO -- "create a culture that rewards good choices." Employers, for instance, should work with "both carrot and stick" to incent employees toward better health behaviors. Physicians need to care more about functionality and cost: "The metric needs to shift."

Underlying such a shift, Zwerner believes, are some basic perspectives "
on which must doctors and employers, indeed, most people knowledgeable about medicine and our healthcare system, might agree." In the most recent issue of IHPM's Health & Productivity Management (Vol. 5, No. 3), Zwerner ticks off 16 of these. He lays them out to open dialogue. I include them here to extend the dialogue to the CAM/IM communities. Are these areas in which you agree?

Zwerner' Proposed Areas Where Employers
and Physicians are in Agreement

Many people who self-refer to primary care physicians
do not need to be seen in the
office. They need
information or reassurance, or they have a minor and
self-limiting condition and are acting prematurely.
Telephone or e-mail "triage" can obviate many
unnecessary visits.

 Many people who do not need to be seen by
a primary care physician can be seen
by another healthcare professional - e.g.,
a nurse practitioner or physician assistant.

 Many people who do need to be seen either do not come
in at all or come in far too late, when things are
out of control, e.g. hypertension, diabetes, dyslipidemia.

Physicians generally are not compensated to encourage
these people to be seen earlier.

Physicians, especially those in primary care, frequently
do not have the necessary time to spend with people
who do need to be seen, especially those with one or more
chronic conditions.
Working people who do not need to be seen prefer
not to miss work.

Doctors generally are available to see patients only
during working hours; they usually are not available early in the
morning, during the lunch hour, in the evening, or on weekends.

 Physicians in primary practice responding to self-referrals
generally are compensated when they see patients and do things,
and not when they spend time educating patients so that they
will not need to be seen so often in the future.

 Doctors get paid to physically evaluate and react to acute
exacerbations of chronic disease - not to proactively manage
diseases or educate and empower patients to engage in self-management.

Many physicians do not have the stff needed to educate people
with chronic conditions and enable them to self-manage their disease.

Physicians comply with evidence-based guidelines about half the time
 - even though such compliance can significantly reduce healtcare costs
and improve workers' functionality and productivity.
 It generally costs more to react to than to prevent
and manage conditions.

Depression is widely under-diagnosed by primary care physicians,
which leads to significant healthcare costs and loss of functionality
and productivity.
It takes longer to educate, prevent, manage and reach out
than to react
Most physicians know little about, and are not measured or
compensated on the basis of, patient functionality,
which can be measured.
 Functionality is what really matters to the employer and the
employee - and so it should matter to the physician.

Source: "A New Partnership Between Physicians and Employers,"
by Alan R. Zwerner, MD, JD. Health and Productivity Management,
Vol. 5, No. 3; 30-31.


Comment: Are you aligned with Zwerner's set of agreements? if not, where are you not aligned? Zwerner's focus was on the employer-conventional MD relationship and "contract." CAM/IM don't show up here, per se. How might this thinking shift if CAM/IM approaches and practitioners are a more conscious and integral part of the story?

Send your comments to johnweeks@theintegratorblog/com
for inclusion in a future Your Comments article.

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