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Medicaid Acupuncture and Massage Therapy Pilot, Part #3: Outcomes Data and Interviews with Patients PDF Print E-mail
Written by John Weeks   

Medicaid Acupuncture and Massage Therapy Pilot, Part #3: Outcomes Data and Interviews with Patients

Summary: In 2002, the legislature of the state of Florida created a pilot program which gave frequently disabled, chronic pain, high cost Medicaid beneficiaries access to the services of licensed massage therapists and acupuncturists. As a pilot project involving over 300 patients in 2006, the state's vendor, Alternative Medicine Integration Group (AMI), was required to annually survey their patients through an independent researcher. This article, Part #3 of the Integrator series on Florida Medicaid Integrative Therapies Pilot, reports data and qualitative information from these mandated patient surveys, SF-12 surveys, and findings from Integrator patient interviews. The short story: beneficiaries speak eloquently about an experience which 93% say reduces pain levels and 84% believe boosts their quality of life. The comments from beneficiaries on this whole system of care are more powerful than the hard numbers. One certain conclusion is that it suggests a public policy of a caring people.
Send your comments to
for inclusion in a future Your Comments forum.

Click here for Part #1, An Overview
Click here for Part #2, "Holistic Nurse Management of Benefit
for Licensed Massage and Acupuncturists"
Click here for a discussion of the pilot's whole system research challenges

1.    Caveat on access

alternative medicine, Medicaid, CAM, integrative medicine
Program sponsor - Florida's Agency for Health Care Administration
A journalist's job can be like that of a visitor to a foreign land in which the government controls what one sees and where one goes. Alternative Medicine Integration Group, an Integrator sponsor, of necessity was my gateway to the practitioners and patients who I interviewed for this story. Confidentiality required that they pre-select patients. As such, I was on a controlled tour.

That said, these patient stories only deepened themes discovered in a third-party survey of beneficiaries mandated by the Florida legislature as part of the Medicaid pilot. That written survey was engaged by an independent investigator. If you want a sample of the direct comments patients made on their experience of care, drop directly to the bottom of this article. I reprint a representative selection of the 81 voices from the independent survey. The chorus of their voices speak to the multiple values in a whole system of care.

2.   Interview with beneficiary Richard Adams

Richard Adams is a 63 year old licensed medical assistant who worked professionally in a mental health clinic in St. Petersburg, Florida. The list of chronic conditions which challenge him began with obesity and diabetes. It was compounded by an iatrogenically-delivered case of Hepatitis C via a blood transfusion. The transfusion was required following a bone marrow transplant related to a cancer. After he contracted the Hep C, Adams "quit work and got really, really heavy." Adams weight topped out at 365.

Medicaid, chronic pain, CAM, integrative medicine, alternative therapies
Richard Adams, program beneficiary
When Adams received the notice in the mail from AMI that he was eligible for the integrative therapies pilot, he responded: "What have I got to lose? I had nothing but time on my hands." In counsel with AMI's holistically-oriented nurse case manager, Adams selected acupuncture treatment: "I'd never had it, never believed in it. I was totally skeptical."

At the time of his Integrator interview, Adams had received 12-15 acupuncture treatments. Adams says he's losing weight - down to 350. His need for blood pressure medication has gone down. He's going to the pool and doing water aerobics. He states: "When I started going to my  acupuncturist I was barely out of my wheel chair. I went from a walker to a cane. Now I can move around without anything. That's how much [my acupuncturist] is doing for me." He speaks of having a more positive attitude: "There's an attitude of support. The surroundings are key. I am taking as much advantage of this situation as I can."

Has the integrative therapies program influenced his other care? Adams ticks through his medical team: "
My GI doc, my podiatrist, my endocrinologist, they all think it's a step in the right direction. They've seen the change. My endocrinologist said: 'Whatever you're doing, keep with it.'"

Comment: Okay, so is it the acupuncture or the pool aerobics that is the active agent? Re-frame: Is typical pharmaceutical treatment or treatment in a whole system such as this is more likely to get people into positive habit patterns?

3.   Cut to the chase: hard data from a mandated survey

Each year, AMI is required to survey beneficiaries to discover subjective information on the outcomes of the pilot project. AMI contracted with Timothy Ketterson, PhD, a clinical psychologist with research appointments with the Department of Veterans Affairs and the University of Florida. Below are findings from the survey of beneficiaries of services in 2006 which AMI reported in July of 2007. They are similar to outcomes an a survey from the prior year. The mailed survey had a 30% response rate - 91 of 306 beneficiaries.

_______________________________________

Beneficiary  Survey Report Data Produced for AMI
to Report to the Florida Agency for Health Care Administration

Prepared on contract by Timothy U. Ketterson, PhD

"IT" = Integrative Therapies


Basics

   

Total surveyed, via mail
     
306
Total respondents
  91
Response rate
  30%

Findings
IT = integrative therapies
 
My provider helped me reduce
my pain level
  93% agree
(55% strongly agree)

 
I am satisfied with the care I
receive from my IT provider
  93% agree
(73% strongly agree)



I believe my quality of daily life
has improved since beginning the
IT program

84% agree
(43% strongly agree)



The IT staff is friendly, courteous
and professional

99% agree
(88% strongly



Overall I am satisfied with the
IT program

93% agree
(71% strongly agree)



I will continue to participate in
the IT program next year

96% agree
(81% strongly agree)



I would recommend the IT program
to friends or family members who
suffer chronic pain or fatigue

96% agree
(81% strongly agree)
     

* AMI stated that it chose to "blind itself to demographic data" in the present survey.
In the 2005 population, 78% were female. Mean age was 47 years old. 82% had
chronic back or neck pain, the others fibromyalgia or chronic fatigue.
AMI assumes the 2006 population was similar.
_______________________________________

Comment:  The basic message is 93% agreed that the program has helped reduce pain levels and 84% believe the care, principally from licensed acupuncturists and massage therapists, helped their quality of life. Also notable, however, both in these questions and the commentary of individuals (as seen at the end of this article), is that the AMI staff helps the positive outcomes. 99% agreed (88% strongly) that the staff are "friendly, courteous and professional." Clearly, part of the therapeutic intervention was the healing environment created by AMI's staff.

4.   Interview with beneficiary Virginia Hatch

"They kept calling my home to get me to start going," recalls Virgina Hatch, a 51 year old grandmother charged with caring for "3 small kids in the house." The housecleaning and care-giving are often associated with what brought her to the program: "I overwork my back and it goes out."

patient survey, Meidcaid, CAM experience, outcomes, clinical effectiveness
Researcher Timothy Ketterson, PhD
Hatch hadn't ever had a massage before she finally relented and decided to see a massage therapist. "It's good for easing tension," she shares.  Her experience is that the benefits of the treatment sometimes lasts 3 days, sometimes 5, sometimes 10 days: "It lasts until the next time I overwork my back."  She speaks supportively about the AMI group: "They're great. I love 'em all. The massage therapists explain what's going on when they hit certain parts of the body during a massage."

Hatch isn't so sure about the value of AMI's educational pamphlets: "Sometimes I read them." But she is clear enough about her experience that she's talking it up: "I've been trying to get my girlfriend next door on it. She's got aches. I recommend it to everybody.

5.   AMI's whole system intention, and patient comments on the nurse case managers

AMI's
Chronic Pain Pilot 2006 Comprehensive Report describes the intent of the broad clinical strategy which the firm established in an effort to create a healing context. (See related column on AMI's whole system.)

The Medicaid waiver and some structures of the beneficiary experience focus attention on the services of the licensed massage therapists and acupuncture physicians (APs) as
they are known in Florida. (APs are non-MD, licensed acupuncturists.)  But these were actually inlaid as "physical medicine services that reduce pain" amidst a broader plan.
"The program helps the patient to move away from the learned dependency of an expensive delivery system by focusing on self-management and helping the patient learn about holistic options and techniques. The program promotes the value of non-invasive, non-pharmaceutical processes such as nutrition, exercise, meditation, and conflict resolution techniques, while providing physical medicine services that reduce pain.  The IT program helps the patient recognize pain triggers and provides support to aid the patient in avoiding unhealthy behaviors while adopting healthier behaviors."
holistic nursing, holitic nurse case management, whole systems CAM integrative medicine
Nurse case manager Tracy Woolrich
The important role of the nurse case managers (NCM) in this system was volunteered by many of the beneficiaries. Examples:

“…I’ve had the pleasure of speaking with Marlene (NCM) on a few occasions; she was extremely helpful and pleasant. Also, (she is) very easy to talk to.”

“The personal interaction and therapy have been an inspiration to me.”

“…I would be lost without the help and care that I have benefited from my case manager, Tracy (NCM) and therapist Michelle (LMT)…”

“You have an excellent staff; they are so caring.  Well, I believe that says it all.”
AMI's Beneficiary Survey Report for 2007 asserted: "A sizable number of respondents indicated that their relationship with (nurse case managers) was just as important to them as the formal treatments they received from affiliated providers."
6.   Interview with Susan Wall

62-year-old Susan Wall is the 4th generation member of her family to have multiple sclerosis.
She has positive progressive MS. Her condition is complicated by a strong chemical sensitivity.

Wall got involved with the Florida MediPass integrative therapies program two years ago. She recalls: "I was on a fast track downhill. I couldn't hardly do anything. I couldn't hardly go out."
A routine part of her list of ailments was "cluster migraine headaches." The choice of provider type - between massage and acupuncture - was easy when she entered the program: "I cannot take massage. It's too painful. I can't bear pressure on my bones."

Image
Florida's Medicaid program
In Wall's telling, the entry into acupuncture treatment didn't come easy: "I was reticent. I had been going to so many dead ends. I didn't think it would work. But when (AMI's nurse manager) called the second time, I said, 'what the heck.'" She recalls that the treatments' therapeutic benefit lasted progressively longer - the first a day, the second "a couple days, the third gave me lasting relief I hadn't had for years."

Acupuncture hasn't been the only component of treatment Wall values. Besides speaking highly of her nurse manager, Tracy Woolrich, RN, she values stress reduction CDs from Health Journeys which AMI provided. She has also valued Reiki treatments case manager Woolrich provided. Wall fast-forwards: "I have so much more energy now. I was homebound. Now I'm not. They gave me back my life."

7.   SF-12 data outcomes show 20% improvements in mental and physical

Part of AMI's outcomes strategy involved administering a functional outcomes measurement tool regarding quality of life called an SF-12.  The nurses administer it during intake to gather baseline data. Follow-up SF-12s are later administered 6 months after intake, and "annually thereafter," according to AMI's co-founder and CEO Jim Zechman. He clarifies: "We mail the surveys to them and follow-up telephonically."


Outcomes of AMI's SF-12 Administration

Measures

  2005
  2006    
SF 12 - Mental function

up 16%
  up 20%
   
             
SF 12 - Physical function
  up 20%
  up 24%
   

All data from reports provided to the Florida legislature
by Alternative Medicine Integration Group of Florida.

AMI concludes: "There seems to be a consistency of improvement with the patient population managed within the scope of the Integrative Therapies Pilot."

8.    Interview with beneficiary Maureen Condron

Maureen Condron's divulges her diverse health conditions
in a forthright, professional manner. A former medical assistant, Condron appears to have internalized the process: "I was in a car accident. I have spinal stenosis, scoliosis, and 2 knee replacements. I'm a type 2 diabetic. I'm in chronic pain. My pain medication, Oracet 10mg doesn't even take it away. I also take Soma 350mg, a muscle relaxer for sleeping. I'm not totally disabled. It's just with prolonged standing or sitting or walking, I'm in pain." She's tried steroid injections, but she can't use them.

Condron recalls that she started seeing an AMI massage therapist after she "got a letter from the legislature" about the integrative therapies program. She used a massage therapist. She comments first on the practitioner: "The massage therapist was wonderful." Then she states that the treatment brought "stress relief." Condron says her muscles weren't as tight, that she gains more mobility. The value of a treatment typically lasts about a week, she says: "The best thing for pain is the program. After a massage, I don't need as much pain medication."

Comment:  Let's be very cynical. Someone tells you that you can have free massage, or free acupuncture. That's what these beneficiaries learned. Did it feel good? You bet. Do you want that program to continue? Well then, talk up the benefits. In short, the beneficiaries' interest in the pilot continuing may be viewed as biasing the outcomes of the survey.

   
 
Whatever decisions the
state of Florida, other
Medicaid providers and
others treating chronic
pain conditions may
reach about this pilot,
one certain conclusion
is that it suggests the
public policy of a

caring people.

 
Yet the authenticity in the voices of these patients is striking. The interviews and self-reported comments (see below) underscore the multitude of ways that these patients derive benefits from the whole system of the integrative therapies program. 

I asked some of those I interviewed what they would think if this pilot were embraced and rolled out nationally. Said Wall, the 4th generation MS patient and program beneficiary:
"We hope they'll continue it. It's far better than anything else. It's better than just drugs. It's decidedly less expensive. There are always side effects and deterioration from drugs. Acupuncture doesn't have them. If we went national it would be tremendous. It would be a miracle, so many would benefit from it. They would save themselves a great deal of money." A deeply subjective projection.

Frankly, after interviewing a few of these souls, my own subjective take was as follows. First, learning of their pains and conditions:
There but for the grace of the universe go I. Second, reflecting on their state of being: They are blessed to have this program. I would wish it on myself were I in any of their situations.

Whatever decisions the state of Florida, other Medicaid providers and others treating chronic pain conditions may reach about this pilot, one certain conclusion is that it suggests the public policy of a caring people.
______________________________

Sample Comments from Beneficiaries
Prepared on contract by Timothy U. Ketterson, PhD

Section 9 of the survey asked patients to describe any benefits they received.
The report includes 81 responses. Here is a representative selection.


"They have loosend (sic) and strongly smoothed out my pain in my neck, back and so on. When I really needed someone to talk with, they were there to help me in anyway that I needed it."

"Well my pain is still there, but I feel a little better when finish my therapy. Also, I would like to try the acupuncture sometimes. Thank you."

"You have an excellent staff; they are so caring. Well I believe that says it all."

"Everyone I have dealt with has been so helpful to me. They've even done things up and above. Without the Massage therapy I would probably be in a wheel chair. They are always there to help me. They are the best."

"An overall lessening of pain, more stamina and an upswing in mood. I want to encourage you to expand the program and allow a patient both massage and acupuncture. It will work even better."

" I feel that I should have 3 or 4 visits a month instead of 2. It would help me out better on my lower back and neck."

"I started with acupuncture about 1 yr ago. I started with 1 visit per week, but since then I have been cut back to 2x's a month. My only complaint is that I finally found treatment that is drug free and now that's been taken from me."

"While I remain in chronic pain. The therapy I've received has allowed me to stop taking RX pain meds, most of the time. This program has been a Godsend. Thank you!"

"Helps relax my muscles from being tense. Helps the soreness in my body from lupus, helps the pain."

"Well it helps my whole right side and lower back. Sue (LMT) is a good person."

"Before, I was in pain, took a pain pill everyday. Now 0-2 a month, Thanks to massage therapy."

"The educational materials and mail outs of community programs have been the most beneficial."
Image
Florida's vendor for the integrative therapies program

"Like medicine, this program has helped me cope with chronic pains. The difference is that prescription drugs have a double edge benefit, consequence (sic); with massages, although it lasts less time than RX, the relief is comforting and safe."

"There has been significant pain relief."

"This therapy program has helped me in many ways. I seem to be able to think and function better mentally and physically."

"Throughout my participation in this program, I not only receive excellent massages for pain relief with a dedicated therapist-(Nicole Longwell, LMT), but have been educated by her on many aspects of my overall health and well being."

"The personal interaction and therapy have been an inspiration to me."

"Since becoming a client of AMI, I have had a more positive attitude towards my illnesses and my whole outlook on life, I would be lost without the help and care that I have benefited from my case manager Tracy Woolrich, RN HHP, and therapist Michelle Hubbard, LMT. I pray this help can and will continue."

"I am more active than I was before."
Source: Integrative Therapies Pilot Project, Beneficiary Survey Report – June, 2007
Produced for Alternative Medicine Integration of Florida, LLC
_______________________

Click here for Part #1, An Overview
Click here for Part #2, "Holistic Nurse Management of Benefit
for Licensed Massage and Acupuncturists"
Click here for a discussion of the pilot's whole system research challenges



Send your comments to
for inclusion in a future Your Comments forum.


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