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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.
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.
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1. For Comparison: The Websites of the CTCA Hospitals 
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)  Tim Birdsall, ND, vp for integrative medicine at CTCA
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)  Other 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 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  The 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.
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.
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)  The 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.
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.
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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