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Will "Integration Light" by Competing Hospitals Kill CTCA's Plans for an Inpatient Facility? PDF Print E-mail
Written by John Weeks   

Will "Integration Light" by Competing Hospitals Kill CTCA's Plans for an Inpatient Facility?

Summary: Cancer Treatment Centers of America (CTCA) wants to build a 24 bed inpatient facility in the greater Seattle area. But CTCA's application for a Certificate of Need (CON) from the State of Washington Department of Health (DOH) has been twice denied. CTCA, known nationally for its pioneering, integrated cancer treatment, argued that its multi-disciplinary, fully-integrative approach was not available elsewhere in the region. Yet, on review of web-based materials from a list of competing hospitals, the DOH denied CTCA's claim. The Integrator approached this article as a Seattle-area consumer. First, CTCA's deeply integrated web presence is explored. Then we visit websites of the competing hospitals the DOH cited as claiming "comprehensive" or "integrated" programs. Do you agree with the DOH's finding? Might the marketing of integration be an over-statement? Which of these reflect action in your own hospitals. Take a look. Then you decide whether CTCA's plans, and patient choice, are being limited by "integration light"?
Send your comments to
for inclusion in a future Your Comments article.

Prelude: A Side-Effect of Over-Selling Integration? For the last decade, hospitals across the country have begun including complementary and alternative medicine (CAM) in their offerings. The movement began after research published in 1993 in the New England Journal of Medicine suggested that a third of adult citizens were using unconventional therapies. Not only were they using these services: they were also spending billions on this care. Hospitals got interested. Money and marketshare are key factors in the CAM inclusion decisions by hospitals.

 
We have all
learned that a
hospital's decision
to market
"integrated" or
"comprehensive"
says very little
about how the
patient experience
may differ, especially
in medicine's inner
sanctum of
in-patient care.



Yet observers will know that talk of "integration" frequently far exceeds actual service offerings. To many hospitals, "CAM integration" may, once explored, be as little as an evening or weekend course on feel-good massage, or a nutrition class from a registered dietician who distrusts all supplements. Very little is in-patient treatment. Meantime, "integrated care" offerings are splashed across the hospital's community magazine. The marketing message: Yes, we have what you want. We're listening. We're responsive. We value complementary and alternative medicine like you do. 

  • But what has truly changed in their inpatient care?
  • What kinds of services are readily available to patients in the hospital?
  • How big is the gap between marketing message and medical practice?

In short, we have all learned that the use of "integrated" or "comprehensive" says very little about how the patient experience may differ, especially in medicine's inner sanctum of in-patient care.


Over-Selling Might Limit Options for Significant Integration

I began this article when I learned of the State of Washington's denial of the Certificate of Need (CON) application of Cancer Treatment Centers of America (CTCA) to get a hospital going
in the Seattle area. (See disclosure note, below.) I spoke with a 20-year colleague, Tim Birdsall, ND, who presently serves as CTCA's vice president for integrative medicine. Birdsall mentioned that the denial included a finding that CTCA was not offering anything distinct from what other hospitals were offering.

 
Is the State mistaking
marketing-driven
"integration light"
for the real thing?

If your answer is yes,
then the CON process,
 believed by many
to be an
anti-competitive
tool,  is being used to

restrict patient
access to more
significantly integrated
cancer care.
 
 
Fascinating. For starters, I knew that Birdsall's title and position at CTCA were unique placements for naturopathic physicians, nationally, in hospitals of any kind. I also knew that he and other naturopathic colleagues were routinely involved, as staff physicians, in in-patient treatment at CTCA facilities. I also believed this was unique. Perhaps I'd missed significant changes in my three years away. If so, I was ready to be happily surprised.

So I
tracked down a copy of the DOH's CON denial on the web. I found out that what Birdsall had said was so. The Washington State Department of Health (DOH) denial states:
"These excerpts [from websites of the effected parties (other hospitals)] demonstrate that other Washington State cancer accredited hospitals ... provide evidence that a similar array of services to CTCA's is available at other hospitals. The department concludes that CTCA is not providing a unique array of services that warrant granting CTCA's Certificate of Need."  (bold added)

I decided to take my own look at the websites of these local hospitals and compare them to CTCA's. You can read what I discovered, or directly visit the links I provide. Then decide whether you think that the State of Washington's denial of the CTCA certificate on this critical point of "unique services" was a just decision. Or is the DOH mistaking marketing-driven "integration light" for the real thing?

If your answer is yes,
the CON process - believed by many to be an anti-competitive tool - is restricting patient access to more significantly integrated cancer care.

___________________________

1.    For Comparison: The Websites of the CTCA Hospitals

Image The CTCA home site opens with an assertion, on its front page, that it is "the home of integrative and compassionate cancer care." A paragraph reads:
Cancer Treatment Centers of America offers patients the most sophisticated forms of surgery, radiation, chemotherapy and in combination with complementary therapies, including nutrition, spiritual support, mind-body medicine and naturopathic medicine ...

The links are all live to descriptions of those integrative services. A separate page describes Complementary & Alternative Medicine. This provides tabs with linked headings titled, "Nutrition," "Pain Management," "Naturopathy," "Spiritual," and "More CAM Therapies." Enter "Naturopathy" and you read:

"Naturopathic doctors are primary health care providers who use natural therapies as part of their treatment plans. Naturopathic medicine may include therapeutic nutrition, botanical medicine, homeopathy, classical Chinese medicine, hydrotherapy, manipulative therapy, pharmacology and minor surgery. At Cancer Treatment Centers of America, you will have access to an onsite naturopathic practitioner who will consult with your physician as part of your integrative treatment program." (bold added)
Image
Tim Birdsall, ND, vp for integrative medicine at CTCA
Hit the "More CAM Therapies" button and you go to a separate CAM page that lists acupuncture, massage, and mind-body medicine and psychoneuroimmunology, as well as the more conventional physical therapy. Go into Acupuncture, for instance, and the consumer reads:
"Acupuncture may be offered it to you by our experienced practitioners as part of your individualized and comprehensive treatment plan." Those wishing to understand "integrative treatment" as expounded by CTA will find a further page which describes their vision, mission, and promises in this area.

 
The CTCA site
offers a welcoming
front door for
integrative medicine.

The patient
finds well-marked

pathways to integrated
services.

The CTCA staff, on the
web, is fully-integrated.

This is the standard
against which the DOH
evaluated the sites
of other hospitals.

 
That is all off CTCA's multi-centered home page. If one then selects from one of CTCA's four facilities (three of them inpatient - Chicago, Tulsa, Philadelphia, plus the outpatient Seattle Cancer Treatment and Wellenss Center), one has the option of clicking on Departments, which include along with Gynecological Center, Radiation center, and Hemotological/BMY Center, the following: Naturopathic Medicine Center, Mind-body Medicine Center and Nutrition Center.

If the consumer clicks on Physicians and Clinicians, one finds a list of names, interestingly, with no evidence of degrees or licenses after them. The list at Midwestern Regional Medical Center (Chicago), for instance, has 22 names, listed alphabetically. The first two, once you click on them, happen to be naturopathic physicians. Various oncology MDs follow. Further down are directors of mind-body medicine, and etc. The lack of titles beside the names - until one clicks in to an individual clinician - invites the consumer to explore and consider. CTCA has, as noted, a vice president for integrative medicine in Tim Birdsall, ND, a naturopathic physician.

Integrative medicine, on the CTCA site, is the welcoming front door, with clear pathways to learning about services. The staff, on the web, is fully-integrated. This is the standard against which the State of Washington DOH evaluated the sites of other hospitals.

2.    MultiCare Regional Cancer Center of Tacoma

The CON denial by the state includes a statement of Multicare that they offer the "most comprehensive center in the South Puget Sound." The homepage refers:
"Cancer care at MultiCare is more than just our doctors and facilities, it's a coordinated system of care that provides prevention and early detection programs, progressive treatment options, many of the latest research protocols, and integrated therapies to help you in your fight against cancer. Our leading cancer specialists and nurses are your partners, beside you every step of the way." (bold added)

ImageOther than a reference to "compassionate care," nothing on the Multicare home page references integrative therapies, CAM, or mind-body. Click on "Treatment Options" and one finds a promise of "a comprehensive, well-coordinated system of care:"
"By drawing from a complete system of care, we're able to offer personalized treatment programs, guided by our healing environment philosophy. No matter what kind of treatment holds the most promise for an individual, the MultiCare Regional Cancer Center gives patients the reassurance of expertise." (bold added)
The page does not guide one to any integrative or complementary care options. Only, at the bottom of the page, without any link or further description, Multicare makes this statement:
"As part of our commitment to holistic care, we offer patients access to a complete spectrum of complementary therapies." (bold added)
 
The most significant
CAM services noted
were massage

and meditation.

The staff listing
is all conventional
practitioners.

If one begins scanning for what this means one finds under Inpatient Services that offerings include "massage, pain management, meditation and spiritual counseling."  Search the Web has nothing explicitly CAM or integrative.  Educational Services includes a link to Yoga classes. Lymphedemia services mention "manual therapies." Hospice and Palliative Care state that their "team of professionals and volunteers provide expert pain and symptom management, psychosocial and spiritual support for our patients and their families."

The most significant find is under Supportive Services - with a subhead of "Integrated Therapies and Other Support." The language is strong here:
"The MultiCare Regional Cancer Center is committed to treating the whole person, not just the disease. So in addition to the most advanced surgical and medical treatments, we give patients access to a wide array of integrated therapies. In addition to their mainstream treatment, cancer patients can take advantage of programs to help manage pain, relieve side effects, reduce stress, and uplift the spirit." (bold added)
The list includes conventional treatment such as physical therapy and rehabilitative medicine, and spiritual counseling, but also massage therapy, meditation instruction, music therapy, support groups, healing and wellness retreats, pet therapy and others. The page also held a link to the Multicare Mind Body Institute. The stated focus is on research and education. Programs are offered from time-to-time as outpatient services.

The Integrator contacted Multicare to learn if any of this was for inpatient care. Todd Kelley, Multicare's manager of media relations said "on the inpatient side, I am not sure to what level we have taken it." He did not provide the Integrator with additional information prior to publication. The out-patient placement was underscored by the site's listing of under Physicians and Staff.  The entire list consists of MDs, ARNPs, plus, under palliative care, a doctor of osteopathy.


3.   Swedish Cancer Institute

ImageThe State of Washington denial of the CTCA certificate includes a statement from the Swedish Cancer Institute  (SCI) that SCI:
 " ... has grown into the Northwest's largest cancer-care program, offering patients the most extensive range of services and expertise in the region." (bold added)
The SCI home pages includes the statements that SCI has:
" ... grown into the Northwest’s largest cancer-care program, offering patients the most extensive range of services and expertise in the region. The Swedish Cancer Institute includes leading cancer specialists, a broad range of treatment options, state-of-the-art facilities and equipment, and cancer care that is as personal as it is progressive and comprehensive ... Our patients benefit from an integrated approach to care. This approach takes into account not only a person’s physical well-being, but his or her emotional and spiritual needs, too. From prevention and early detection, to state-of-the-art treatments and complementary therapies, to supportive and palliative care — the Swedish Cancer Institute is designed to meet the individual needs of each of its patients." (bold added)
The page includes no links to complementary or integrative therapies. Treatments also has no direct reference to CAM or integrative medicine. Treatment Team introduces a prospective patient to its medical oncologists, then notes that patients "may receive support" from a team that includes "nutrition counselors," "psychosocial specialists" and "rehabilitative specialists." The picture is of a kind of integration, and team medicine, but with a restricted team of apparently conventional practitioners.

In a similar positioning as Multicare, SCI's Patient Support Services page opens to additional options such as counseling and nutrition and leads with Complementary Therapies. Here the prospective patient learns that there are certain "non-medical" services available, via  five PDF files: Art Therapy, Music Therapy, Massage Therapy, Meditation, and
Naturopathic Services. The phone number on the PDF takes one outside of the hospital to the North Seattle offices of Northwest Natural Health, roughly 20 minutes away.

   
While Swedish  looks
good on an "integrated
care video," the actual
CAM and integrative
services  are only
listed  in "Support
Services" and as
attached PDF files.

CAM is presented
as "non-medical."

The phone link to
massage and
naturopathic services
take you to offsite
contractors.


The Integrator contacted Dan Labriola, ND, the founder of NWNH. Labriola said that he and two NWNH naturopathic doctors associates are privileged to see patients onsite in Swedish. He's "been on staff for two years." Asked how many patients he sees in a given period, Labriola said there are "always a lot of referrals" but said specific numbers were proprietary. What about not being listed as a staff member? "Naturopathic staff is different than medical staff," says Labriola, adding: "They are so ensconced in a way I prefer not being on it."

Notably, the
Educational Resources section has no specified information on CAM or IM. A button, however guides one to a well-produced Integrated Care Video. This embracing portrayal of the SCI approach includes a clips of Labriola, interviews with other Patient Support Service workers, together with  affirmations of the value of CAM therapy to patients and Swedish' commitment from some members of the Swedish oncology staff. Mentioned are "full time massage therapy services" now available at one campus, and that one pain specialist is a board certified medical acupuncturist.

Notably, the All Services  button on the Swedish Medical Center site has no links to any of the CAM or naturopathic services mentioned in the video. The list of "physician names and contacts" only includes MDs. No names of any CAM providers appeared to be listed anywhere, except inside the 20 minute "Integrated Care" video.


Many of the
hospitals listed
by the DOH 
offer nothing more
than sets of
conventional
practitioners
arranged
in teams.



 
4.   Seattle Cancer Care Alliance

The State of Washington's denial of CTCA's certificate of need application also notes a statement from the Seattle Cancer Care Alliance that they "bring together the best of three internationally reknown cancer-care institutions: Fred Hutchinson Cancer Research Center, University of Washington Medicine, and Children's Hospital and Regional Medical Center." They thus create:
"  ...  the only federally-designated comprehensive cancer center in the Northwest." (bold added)
The home page includes nothing about CAM, complementary therapies or integrative medicine. Departments are all conventional. There is some mention of support groups on the UW medicine site. If there is any "integrative care" such as CTCA proposes, it is well hidden.

5.   Overlake Hospital

The State of Washington's denial of CTCA's certificate of need application also notes a statement from the Overlake Hospital Cancer Center that it offers "world-class cancer care ..."  However, the site only lists Cancer Services not a "Cancer Center." The Cancer Care Team is all conventional.

6.   Evergreen Hospital Medical Center

The State of Washington's denial of CTCA's certificate of need application also notes a statement from the Evergreen Hospital Medical Center that it:
" ... offers an integrated, multidisciplinary approach to cancer care that puts the program's full resources to work for every patient in a warm and supportive environment." (bold added)
ImageThe home pages has no link to CAM or integrative services. A little search discovers that there appear to be some support services. The cancer team is "multidisciplinary," but there is no clarity on what practitioner types are included. The hospital, a few miles from Bastyr University, which offers advanced degree programs in naturopathic medicine, acupuncture and Oriental medicine, and whole foods nutrition appears to have no web-visible relationships with these professions.

7.    Good Samaritan Cancer Center

The State of Washington's denial of CTCA's certificate of need application also notes a statement from the Good Samaritan Cancer Center (GSCC) that it:
" ... embraces a holistic, patient-centered style of cancer care. (bold added)
GSCC is an affiliate of Multicare. Neither the home-page nor the Inpatient Care page mention any CAM or integrative medicine. A "Comprehensive Care Close to Home" button yields the reference to holism in the quote noted above. An internal button here links one to Support Services where a number of services such as nutrition, pastoral counseling and psychosocial programs are noted. No mention of complementary therapies or integrative services or any CAM providers. The list of Our Services for the entire system is similarly devoid of any such references.


Analysis and Comment:  The websites of all these cancer centers are sales tools. They are entry-ways for businesses in which each patient who walks through the door represents $75,000-$100,000 of hospital revenue. In short, this public relations and marketing game is serious business. Without analysis of, and experience of, what is behind the virtual presence created by either CTCA or any of the others, no firm distinctions between the two can be made.

Yet it was just such a review as I engaged here, of information provided by the hospitals, that led the DOH to conclude that:

"CTCA is not providing a unique array of services that warrant granting CTCA's Certificate of Need." (bold added)
What is your sense? Is this just?

Comparing CTCA with Swedish


Clearly, only the Swedish Cancer Institute comes anywhere near to resembling the CTCA arrray of services. Yet a close look draws a profoundly disconcerting portrait of how marketing may be mistaken for actual integration.

 
Swedish's apparent
embrace
of CAM in its
"Integrated Care" video
is discordant with the
hospital's broom-closeting
of the CAM services and
providers on the site. 

CTCA deeply engages the patient's experience of integrated care and naturopathic medicine from its homepage inward, integrating these and other complementary practitioners, including those offering nutrition and psychoneuroimmunology, into the CTCA staff listing. Anyone familiar with hospital politics will know what an accomplishment that is. CTCA recognizes these services as departments, and appoints department heads. The overall director of integrative medicine is Birdsall, a naturopathic physician. Birdsall holds a corporate title as vice president. To my understanding, this is a unique, in the nation, for valuing the potential contributions from the most throughly trained professionals in the United States.in integrating natural health care and Western medicine.

The Swedish site, by comparison, requires a meander through a few buttons and a "support services" guess before arriving at the "complementary therapies." These we are told are "non-medical." We are then linked link to a handful of PDF files. This is the figurative broom closet of the SCI website, where CAM services are stored. The phone lines to massage therapy and naturopathic services take you offsite, to independent contractors. None are listed as staff. Swedish's apparent embrace of CAM in its "Integrated Care" video is discordant with the hospital's broom-closeting of the CAM services and providers on the site.

Bottom line: Swedish has taken some steps toward broadening the patient's options and may be an interesting story of how to give CAM a presence without messing around with the medical-political issues of deeply integrating it with inpatient services. Swedish may also be a story of how to respond to a competitor (CTCA has been pursuing this facility for years) without, actually, doing much. But there is nothing here that questions the uniqueness - perhaps nationally - of what CTCA's site promises.

How Can We Explain the DOH's Finding of "No Unique Array of Services?"

A friendly view of DOH's finding suggests that DOH cannot
distinguish between projected image and substantial programs. Or perhaps the DOH does not value CAM and integrative services enough to make such distinctions. At the least, their declaration that CTCA is not unique signifies a lack of respect for the significant subset of the population who know and value integrative medicine.

 
One cannot help
but conclude that
the oligarchy of
existing hospitals
has circled the
wagons and is
using the CON
process to keep
the unconventional
outsider - CTCA -
out of their
lucrative business.

One tool of the CON
is the marketing of
"integrated care."

 
This disrespect shows in other important ways in the DOH's decisions. CTCA asked that its application be viewed differently because it anticipates drawing patients from throughout the Western United States and abroad. CTCA's other hospitals, because of their unique mix of services, draw patients nationally and internationally. The DOH refused to consider this potential value.

More importantly, CTCA's uniquely integrated services, as presented on their site, are an attempt to bring to bear new cancer treatment options on a set of conditions which can only be expected to increase their incidence as the toxic loads of bad habits, lousy food and poor environment increase. The DOH showed no sensitivity to the contributions to a patient's experience and life the CTCA model might bring.

Here my response is personal, as a Seattle resident. I want the option of this facility for myself, my family and my friends. I want CTCA to continue to raise the bar for what we can expect in integrated cancer treatment.

CTCA's problem, however, is likely deeper, and more mundane than mere disrespect. The certificate of need (CON) process
was put in place by legislatures as an attempt to control costs. The CON, living up to its acronym, is now viewed by many as little more than a mechanism by which existing facilities control competition.

One cannot help but conclude that the oligarchy of existing hospitals has circled the wagons and is using the CON process to keep the unconventional outsider - CTCA - out of their lucrative business. A new tool of the CON appears to be the marketing of "integrated care" when all a competing hospital is offering is "integration light."

In participating in the CON, the DOH is not only killing competition, it is also killing choice. By killing choice,the DOH may actually be diminishing the quality of life, and the length of life, for many cancer patients. To the extent that CTCA's integrated care can prove to slow or stop the growth rates of cancers, the DOH, in killing a hospital, is also - to be quite blunt and to the point - killing people.

The DOH should reconsider its ill-advised decision.

Disclosure note: I learned about CTCA's certificate of need issues when I contacted Birdsall, CTCA's director of integrative medicine services, on the suggestion of an Integrator advisor, to explore CTCA becoming an Integrator
sponsor. I had known of the pioneering inclusion of nutritional services, including supplementation, at CTCA's flagship hospital since the mid-1980s. My own relationship with CTCA goes back to 1996 when I helped introduce CTCA to the naturopathic medical profession. They were later co-sponsors of an Integrative Medicine Industry Leadership Summit I helped convene. So, while the context requires disclosure, in many respects what is at play here is an "alignment of interest" rather than a "conflict of interest." This is particularly acute since I, as a Seattle resident, would like to have CTCA's inpatient services available to me and my family, friends and colleagues here, should the need arise. My spouse and I already routinely refer friends to CTCA's outpatient facility.

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