Alternative Medicine's Medicaid Integrative Pilot and the Importance of Whole Systems Research
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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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.
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.
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)
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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