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Making Amends: Studies of Effectiveness and Cost-Effectiveness Represent <1% of NCCAM Budget PDF Print E-mail
Written by John Weeks   

Making Amends: Studies of Effectiveness and Cost-Effectiveness Represent Less Than 1% of NCCAM Budget

Summary: Are effectiveness and cost-effectiveness the most useful questions about natural healthcare and integrative medicine? My guess is that for consumers, employers, government agencies and policy makers, the answer is undeniably yes. Not so the NIH. Since 2002, just 1% of National Center for Complementary and Alternative Medicine (NCCAM) funds have targeted these questions. The Integrator reported last issue on an exciting new NCCAM initiative which may begin to address this awful shortcoming. Here are the supporting data and the recommendations from the Institute of Medicine that are behind the new NCCAM program as presented by Richard Nahin, PhD, MPH, the NCCAM officer in charge of this program.
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HSR, health services research, CAM, integrative medicine, cost, cost-savings, cost-offsets, NCCAM, alternative medicine, cost savings
Richard Nahin, PhD, MPH, health services research leader at NCCAM
Last issue, I provided some perspective and details about a new concept paper which was approved by the NIH National Advisory Council for Complementary and Alternative Medicine on September 5, 2007. That program will look at effectiveness and cost-effectiveness of complementary and integrative approaches as practiced in a community setting. It's been a long time coming.

I contacted the NIH for an interview with Richard Nahin, PhD, MPH, the long-time NCCAM staff member who presented the concept to the advisory council members. That agency's public affairs department turned me down. I have gathered from colleagues who know the NIH better than I that I shouldn't take it personally. The agency which favors controlled trials also strongly favors controlled media.

Yet the NIH was also very helpful. They sent a copy of the powerpoint slides that Nahin presented to the Advisory Council on September 5, 2007, in support of the concept. Here are some highlights from Nahin's 12-slide presentation.

NCCAM Funding of Effectiveness & Cost Effectiveness
as a Portion of NCCAM  Budget

Type of HSR Research
   2002   2004    2006   

Outcomes (effectiveness)
  0.68%   0.40%    0.40%   
Cost    0.45%   0.0%    0.24%   

Cost + Effectiveness




Based on estimates from points on a line-graph in a powerpoint.

The Rationale for Health Services Research: Institute of Medicine and NCCAM Recommendations

Nahin's presentation at the advisory council began with some elementary education. The concept paper is formally focused on "
Outcomes, Cost-effectiveness, and the Decision Process to use CAM." All areas represent targets of "health services research" (HSR). Nahin offered the definition of HSR used by the US Agency for Healthcare Research and Quality (AHRQ):
"Health services research (HSR) examines how people get access to health care, how much care costs, and what happens to patients as a result of this care.”
ImageWhile the AHRQ is the federal agency with core responsibilities in this area, HSR is one of 10 domains which NCCAM has identified as important in its strategic plan. Nahin notes that HSR approaches can be useful for numerous reasons. HSR approaches can:

  • Help understand why individuals and populations use CAM interventions
  • Examine the "individualized and multi-modal" nature of CAM
  • Capture outcomes in "real-world settings"
  • Determine quality of care and access in "integrated healthcare delivery models"
  • Be a less expensive research option compared to randomized controlled trials (RCTs).

Another major area of potential value is cost of treatment. Nahin notes that HSR approaches are the best way to see the impact of CAM use on costs. Do complementary interventions add to the costs of conventional care? Or do they replace or lower them? What is the cost of combined CAM plus conventional versus either alone? Nahin notes that the 2005 report from the Institute of Medicine on CAM in the United States specifically recommends that HSR be engaged. The IOM urged studies which ask:
"Are models of integrative medicine cost-effective when compared with the cost of care obtained in conventional medical practice settings?"
Nahin noted that IOM's HSR-related recommendations also focused on exploring why consumers and practitioners choose to use CAM.


Total Health Services Research* as a Part of NCCAM Budget
(R01 and R21 Grants)

   2002   2004    2006   

Total HSR projects funded
   11    10     
Percent of total NCCAM Budget
   2.75%    1.85%   1.55%   

% is based on estimates from points on a line-graph in a powerpoint.

* Other forms of HSR included, besides cost and outcomes noted above, are examinations
of those who use the services and exploration of why they use the services.

Overcoming a Neglectful Legacy

In his slide show, Nahin rhetorically asked: "So what is NCCAM's commitment to HSR?" All health services research was at its peak in 2002 with 11 projects. This represented roughly 2.75% of NCCAM's budget. Four years later there were just 5 projects funded, representing 1.55% of the NCCAM budget.

Yet only a fraction of these funds actually looked at effectiveness and cost-effectiveness. In 2002, funds for these tow types of explorations totaled 1.1% of NCCAM funds, a portion which dropped to an even more miserly 0.64% just 4 years later.

    In short, the most significant
questions NCCAM could be
asking - from the perspective
of consumers, employers,
policy makers, community
Medicare, Medicaid,
insurers and managed care
organizations  - received less
than a penny of the NCCAM

In short, the most significant questions NCCAM could be asking - from the perspective of consumers, employers, policy makers, community clinics, Medicare, Medicaid, insurers and managed care organizations - received less then a penny of the NCCAM dollar.

Making Amends: "
Encourage research in actual healthcare settings"

's slide show then lays out the simple rationale for the new initiative:
"NCCAM is not taking advantage of scientific opportunities offered by current public use of CAM to study CAM in 'real-world' settings as outlined in NCCAM Strategic Plan and IOM Report on CAM."
The new program's objectives, then, will be "to encourage research on how CAM therapies function in actual healthcare settings." The program will have "an emphasis on observational studies and secondary data analyses."

Comment: I had the opportunity this past week to spend considerable time with a health services researcher with over 30 years of experience analyzing diverse state, federal, private, not-for-profit and corporate projects. I asked him, point blank - and not for attribution - why he thought it was that we have had but pennies thrown in the direction of cost and effectiveness studies, given their potential value. His response was immediate, and blunt: "It would give them credibility."

I asked a top-flight
health services researcher
why so few dollars
were spent to look

at effectiveness and

His response was
immediate: "it would
give them credibility."

While the "them" my colleague was referring to was the integrative practices and licensed CAM disciplines struggling for legitimacy, I think now of the credibility, before Congress, that positive outcomes in these areas might produce for NCCAM. The not yet 10-year-old NCCAM has its own credibility issues given the negative outcomes of so many NCCAM-funded RCTs.

Interestingly, given my colleague's comment, the decline of resources witnessed here has come at a time when the percentage of members of the NCCAM advisory council who are from licensed disciplines has also slipped significantly. As noted in a prior Integrator article, the Congressional mandate which established NCCAM calls for at least 50% to be licensed members of the disciplines NCCAM is charged to evaluate. This was the council's make-up in 2002. However, the present council has drawn only 28% of its members from the licensed disciplines. These are the very disciplines which operate in the real world by drawing consumers into their practices.  These are the professions most likely to have a chance to gain credibility through an aggressive HSR agenda.

I only note this association. It is possible that the parallel decline in licensed members of the advisory council and in studies that might quickly earn their practices credibility is no more than a coincidence.

Whatever the past, the present program which Nahin introduced for NCCAM on September 5, 2007, is an opening into a more useful research future for NCCAM. And with this program, the question now becomes a kind of put-up or shut-up: Do natural health care disciplines and integrative medicine practices and businesses have the focus, the self-confidence and wherewithal to seize this opportunity to gain recognized as the effective and cost-effective interventions they believe they represent?

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