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Alternative Medicine's Medicaid Integrative Pilot and the Importance of Whole Systems Research PDF Print E-mail
Written by John Weeks   

Alternative Medicine Integration Group's Medicaid Integrative Pilot and the Importance of Whole Systems Research

Summary:  The Medicaid integrative therapies pilot has huge variability of care. Included may be various conventional services, mind-body CDs, massage and acupuncture and chiropractic care from licensed practitioners, educational materials, counsel from a holistic nurse, and more. Can anything with this kind of variation be a "pilot" project? Richard Sarnat, MD, AMI's co-founder, provides a perspective which begs a second question. Given that all integrative practices show great variation and individualization, what model which is less complex could possibly be considered a pilot? A line in the sand for the future of integrated health care research becomes more visible.
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This column is based on Section 10 of Part #2 of the Integrator report
on the Medicaid pilot.


The Medicaid integrative therapies pilot program in Florida attempts to honor the complexity of a whole system of care. This system, because it is whole, includes cost. Funny how even the most progressive of whole system thinkers will forget that, oh yeah, cost is part of life.

managed CAM, managed care, cost effectiveness of CAM, insurance and alternative medicine, integrative medicine
Vendor to Florida on the Medicaid integrative therapies project
For those interested in advancing such a paradigm of treatment, this project, operated by Alternative Medicine Integration Group (AMI), an Integrator sponsor, is a learning laboratory. At the same time, with AMI's client focus and great variation in treatment, the AMI project raises a fundamental question about this project’s value.
Given the variability, can we still make judgments about the clinical and cost outcomes of the project which can be useful to others?
The variability in the AMI treatment model is huge. First, patient care has a range of inputs. These can include mind-body CD's, massages and/or acupuncture treatments, counsel from a caring holistic nurse, conventional services, chiropractic, community support groups, educational materials and home visits. In addition, AMI's “re-invents” aspects of its program when it sees ways it believes it might better meet client needs.

In short, a researcher trained only to examine single agents in placebo-controlled trials would probably break out in hives upon looking at this pilot, if not end up with a frank case of the heebie-jeebies.


But can we make judgments based on this pilot? I put this question to Richard Sarnat, MD, AMI's co-founder. Sarnat says he believes the answer is yes and no. No, he says, because every personalized variable is not included and accounted for within the research design. There is "background activity" not captured. But yes, Sarnat asserts, because the charge from the state of Florida was to pilot a program which could improve clinical outcomes and create a global reduction in the costs associated with these populations. As was referenced in Part #1 of the Integrator series, and will be explored more deeply in Part #3 (clinical outcomes) and Part #4 (cost outcomes), AMI has been gathering outcomes deemed useful to legislators and policy-makers. In fact, AMI’s performance led the state to expand and extend the program.


whole systems research design, integrative medicine, complementary medicine, alternative medicine, payment, insurance
Richard Sarnat, MD, AMI co-founder
I look at the AMI model and think how familiar it is. Yes, the design may drive a conventionally-trained and practicing researcher into emetic fits, or into chortling disdain for anyone who could even imagine that outcomes from this pilot could possibly be meaningful. But the truth is, AMI’s combination of great diversity of inputs, use of multiple practitioners, individualization of care, and shifting of treatment protocols is not only not exceptional in integrative treatment. Such polymorphous variability is the rule.


These variable components characterize the care a person can be expected to receive in any self-respecting integrative medicine clinic or from any whole person-oriented practitioner. The care manager may be a holistic nurse, as in the AMI model. Or he or she may also an integrative/holistic medical doctor, naturopathic physician, broad-scope chiropractor or general practitioner of traditional Chinese medicine. The elements of treatment remain the same.

This isn’t assertion. Look at the diversity of practitioners and modalities which necessarily go into whole-person treatment as defined by the most conservative of these integrative providers, the academically-based conventional medical doctors. Here is their definition of “integrative medicine:”

Integrative Medicine is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.

- Consortium of Academic Health Centers for Integrative Medicine (www.imconsortium.org)

whole system research, definition of integrative medicine
Integrative medicine definition of this consortium of necessity a whole system of care
This definition calls for engaging great variability. AMI’s model is an example of this norm. This is what we need to be researching.

Sarnat, AMI’s medical director, is blunt in his assessment of the division between research models:  “For those scientists who in their reductionistic model must have a mechanism of action or an isolated primary variable, this type of research will always fall short. However, for those of us who only care whether the patient ultimately gets better in a cost-effective manner and who can live with the fact that in a highly variable world and treatment setting we cannot reduce this to a single variable or mechanism, this type of research will do. Two different goals; two different research criteria.” Then Sarnat adds: “I'll settle for the mysterious; an unexplained but better world.”


I believe there is a line in the sand here. The ugly truism about most reductive researchers is that they would rather know something perfectly well that is meaningless than discover something that could be extremely valuable but which cannot be reduced to a simple cause. For example: a potentially better, complex system of care for disabled, costly and underserved Medicaid patients who are in chronic pain.

To honor what we practice and advocate, we must embrace the mysterious and unexplained. We must demand that this direction for research be not a peripheral subject pursued with .65 one-hundredths of the NIH NCCAM research budget. To honor our practices and our patients, such explorations must be placed front and center. They should dominate our inquiry.

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