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Forum on IOM Summit: Comments from Participants Kreitzer and Simons and Planning Team's Goldblatt |
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Written by John Weeks
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Forum on IOM Summit: Comments from Participants Kreitzer and Simons and the Planning Team's Goldblatt
Summary: Among
the 650 participants in the IOM Summit were a few score professionals
who were invited by the IOM, and in some cases contracted, for specific roles. Among these were Mary Jo Kreitzer,
PhD, RN, FAAN, director of the Center for Spirituality and Health at
the University of Minnesota and a long-time promoter of
inter-disciplinary education and practice. Kreitzer had dual roles. She
was contracted to lead multidisciplinary team on a paper and she presented on a plenary panel. Elizabeth "Liza" Goldblatt,
PhD, MPA/HA had four significant roles: Planning Committee, moderator
of the panel on which Kreitzer served, facilitator of an "assessment
group"on imagining the future of integrative practice, and wrap-up panel member. The third report here, from Michelle
Simon, PhD, ND, was invited to be a member of an assessment group on "designing and
building the economic incentives." Simon focuses on her take-home of key changes we need to create a healthcare system. Enjoy the diversity of perspectives. We have the "ways" to do what we need. Do we have the "will"?
For other articles in this Forum:
1. Mary Jo Kreitzer, RN, PhD, FAAN: Summary of key points in a shift to health
Mary Jo Kreitzer, RN, PhD, FAAN,
has played a unique and powerful role in the development of
academically-based integrative medicine, or "integrative health," her
preference as both nurse and healer. From her base at the Center for Spirituality & Healing at the University of Minnesota, a  Mary Jo Kreitzer, RN, PhD, FAAN
founding member of the Consortium of Academic Health Centers for Integrative Medicine,
Kreitzer remains the only nurse-director of a member program. Her work
speaks volumes: maintaining a focus on healing and interdisciplinary
efforts, notably through strong inclusive relationships forged with the
Northwestern Health Sciences University
that offers programs in chiropractic, AOM and massage. Kreitzer is her
Consortium's past vice chair and is known for keeping her eye on the
prize: healing. She was invited to multiple roles at IOM, including
lead author for a paper (in a group that included an MD, MPH and a DC, MPH) and
part of a plenary session on her same topic, Education and the
Workforce. Kreitzer modified the following for the Integrator from an informal note she sent to friends and colleagues shortly after the meeting.
A Few Highlights:
Mary Jo Kreitzer, RN, PhD, FAAN
Over 650
attended. By all accounts, it was the
largest and most diverse group ever assembled to focus on integrative
health.
The language
issue - it seems as though the field is quickly moving to a consensus that the field should be called
integrative health - not CAM, not integrative medicine.
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As this has been a thorny
issue for so long,
I cannot
tell you how amazed I was
to hear speakers by the end
of the
conference referring
to it as "integrative health."
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Harkin
announced that he will even propose a name change for NIH NCCAM. It could become National Center or Institute for
Integrative Health (or medicine). Preference seems to be for health. As this has been a thorny issue for so long,
I cannot tell you how amazed I was to hear speakers by the end of the
conference referring to it as "integrative health."
While the Consortium for Academic Health
Centers for Integrative Medicine will not change it's name, I sense that
language around health reform will focus on integrative health. Another language issue: Harkin made a big
point of emphasizing that he would be calling this health reform, not healthcare
reform.
Other big
themes:
- Need to shift
from focus on disease to health
- Align
integrative health with wellness and prevention movement
- Expand primary
care provider to include NP, PA, other licensed CAM providers
- Need
fundamental reform in education as well as care delivery
- BIG focus on
empowering patients to Take Charge of their Health.
- Some of the
CAM community would like the CAM label to entirely go away.
- Lots of
conversation around whole person care - getting away from labels of consumer or patient
Comment:The synopsis of themes
agrees with that of Claire Johnson, DC, PhD. One of Kreitzer's
strongest points, during the week, she made on the Hill, speaking
before US Senator Barbara Mikulski (D-MD). She suggested that one way
through our crisis, especially in reaching the underserved, is expand
primary care to include nurses, physician's assistants, naturopathic
physicians, chiropractors and others and have them form relationships
with community health centers to form a unique community based health
care. Now there is some vision! If most MDs don't want primary care,
then give it to those who do!
2. Elizabeth "Liza" Goldblatt, PhD, MPA/HA
: Elements of a "Splendid Success"
 Elizabeth Goldblatt, PhD, MPA/HA
Goldblatt has been a leading educator in acupuncture and Oriental
medicine for two decades. She served as president of the progressive
Oregon College of Oriental Medicine, in Portland, Oregon, as chair of
the Council of College of Acupuncture and Oriental Medicine, and as
vice president for American College of Traditional Chinese Medicine. In
each position, she has fostered multi-disciplinary and
inter-institutional relationships with both other natural health disciplines and her conventional counterparts. Goldblatt currently
serves as the chair of the Academic Consortium for Complementary and Alternative Health Care
(ACCAHC - www.accahc.org), a position where I have the pleasure of working
closely with her as executive director. This posting was modified by Goldblatt for Integrator publication from a
report she wrote for ACCAHC leaders.
Overall, I
would say that the IOM/Bravewell Summit on Integrative Medicine and the Health
of the Public was a splendid success. Please go to the IOM web site
to hear the conference.
Many
are saying that this IOM
meeting is, literally, history making. Many, including the organizers,
panelists, the organizing committee and keynote speakers, are very
enthusiastic about being sure that our work continues. We all also felt
strongly that ideally the IOM, which is so well-respected - will continue
to take some level of leadership role in further developing the ideas and
recommendations that were presented throughout
the Summit.
I believe that there was very powerful consensus,
generally-speaking, on the critical importance of shifting from a disease-based
system to a wellness one - (from cradle to grave) and in collaboration among
health care practitioners and educators. In so many areas, there was good solid
agreement.
As ACCAHC
Chair, I was on the Planning Committee which was a powerful experience and
consisted of an excellent, really bright and motivated group of individuals.
During the Summit, I was involved in 3 specific areas:
1) I moderated
a priority assessment group on how IM (Integrative Medicine) will affect
health care reform;
2) I
moderated the panel on Education and the Workforce and
3) I was a panelist on
the final wrap-up panel.
1. There
were some very powerful and influential people in the assessment group.
Our meeting was open, warm, and cordial, and we quickly reached
consensus on the 3-4 major areas that involved IM in US health care
reform. Reed Tuckson did a superb job in summarizing our main points.
Please see the IOM web cast for his presentation.
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We reached consensus that
there must be Inter Professional
Education so that all health care
practitioners can
understand
and refer to each other.
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2. Next, I
moderated the panel on Education and the Workforce. The panelist were
excellent and we also reached consensus that there must be IPE
(Inter Professional Education) so that all health care practitioners can
understand and refer to each other; that it is time to expand the first point
of contact person to include such practitioners as nurse practitioners, PA's,
DC's, ND's, LAc's; we agreed that it is time to train clinicians to work in
teams - at the didactic, clinical and research levels (especially in outcomes
research); that it is time to put the patient first and end turf issues; that
we must shift from being a disease-based health care system to wellness
one, and take this approach into our communities; that wellness visits
must be properly reimbursed; that we must begin with less invasive treatments
before using more invasive treatments (ex: DC and or massage for lower back
pain before surgery/ acupuncture for migraine before meds/nutritional analysis
by the ND before going to meds, and so on). Sir Cyril Chandler, MD, a
delightful colleague from the UK stated "Do No Harm and Do Some
Good." Again, please read the transcripts or look at the webcast.
3. The wrap
up panel was stimulating and strong. My presentation briefly focused on
the main points from our panel and then I went on to tell a story about
how when Tibetans first came to this country in the late 60's and early
70’s they kept asking me why "Americans don't seem to like
themselves." Now - with almost 2/3rds of our population being overweight,
almost 1/3 obese, 90 million pre-diabetic or diabetic, and with so many people
on anti-depressant, one must ask if these are signs of a 'happy,
healthy country.
Then, I mentioned that over a decade of discussion with
Tibetans about this subject, we agreed that some of the major reasons were lack
of community, no safety net, too much greed, too much emphasis on
more, being out-of-balance with nature, too much emphasis on being
workaholics, too much emphasis on self, and not having
a government approach that truly manifests caring for others,
etc. I must confess, I decided to speak from my heart and made several
strong statements including that we are the only country in the developed world
without universal health care, that health care was affected by "greed of
the some" (a statement by President Obama) just as Wall Street and the
banks have, that it was time to put the patient first and remove our own turf
issues, and that we need a 'value revolution' that involves caring for
others.
I did come back to my belief that we are all in health professions because we are basically caring and compassionate (even
if studies have shown that while in medical school, students' levels
of empathy goes down) and we have the motivation is to help/heal and work for
the benefit of others. And, for those of us who are educators, we are
passionate about the importance of education being the main way to change
humanity and create a saner, caring and compassionate world.
Comment: I found especially powerful Goldblatt's closing comments on the perception of the Tibetan monks that we are unhappy and "don't like ourselves." Somehow we need to engage that, to re-frame the American dream to be happier and enjoy life more than the generations before us who mostly strove to get more things. Yes, we're talking European safety net (yes, you will have food, clothing, shelter, health care) as a starting place. Then we integrate into that.
Michelle Simon, ND, PhD: Key Take Home on Elements of a System of Health
Michelle Simon, ND, PhD  Michelle Simon, ND, PhD
served on the same IOM assessment group on which Richard Sarnat, MD, served (see Sarnat's report here) which focused on designing the economic incentives to make integrative health successful. Her value to that group derived from cluster of professional roles. She is a clinician with Seattle Healing Arts, perhaps the nation's largest integrative center. (For a list and diversity of practitioners, click here.) Simon also brought to the IOM her experience on the Health Professional Loan
Repayment and Scholarship Committee for Washington State and the State's Health Technology Assessment Committee. Simon focuses on the key take-home issues which she believes need addressing to move us toward a healthcare system.
In returning from the
Institute of Medicine Summit on Integrative Medicine and the Health of the
Public, I see several issues to be addressed in order to achieve a true health
care system in the US versus the disease care system we currently provide.
Evidence-
based medicine. I
believe that the budget for healthcare in the US need not expand in order to
achieve better health for all Americans.
Our challenge is to appropriately reapportion the current
expenditure. In Washington State we are achieving
this with an evidence based evaluation of current and proposed healthcare
technologies. Our committee, the Health
Technology Clinical Committee (HTCC) seeks to base coverage decisions on
evidence that a medical procedure, device, or test is safe, effective and
provides value. Our decisions apply to
all state managed healthcare plans. These types of technologies and interventions
generally represent a large portion of the healthcare dollar spent in America
today. As one hospital internist pointed
out at the Summit, we spend 50% of our healthcare dollars in the last week of
life. What he didn’t mention was that it
is spent on technological and pharmaceutical interventions. This speaks to the fact that we are dealing
with a healthcare “industry”. For this
industry, there are plenty of economic incentives in place already.
The incentives to adopt new interventions and
technologies are numerous. Not the
least of which is the significant profit that companies marketing new
interventions will achieve. They, in
turn provide incentives to providers to promote and adopt new
interventions. Academicians and
clinicians are provided grant money and fees to join advisory boards and speakers
bureaus. Financial assistance is
provided to prepare review articles, enhancing academic careers. Patients are provided free samples, at least
of medicines. Those medicines are
heavily marketed on television, creating further demand.
The incentive I see lacking is one of
rewarding scientifically proving that the new intervention is superior- safer,
more effective, and cost effective. I
believe it is crucial that a new intervention be all three. One way to achieve this is through
organizations like our Washington State HTCC which provide an incentive to
complete the evidentiary studies to prove an intervention is indeed superior to
current best treatment. If we demand
these studies, they will be done.
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It is
quite surprising to see
how poor the evidence basis is
for many current
technologies.
In our first year, we saved
the state of Washington
approximately $20 million
by
making non-coverage
decisions on six of ten
reviewed interventions.
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Some of those decisions were on Upright MRI,
Pediatric Bariatric surgery under age 18, Discography, Virtual Colonoscopy,
Intrathecal Pump for delivery of pain medication in non-cancer chronic pain,
and arthroscopic knee surgery. I believe
a retroactive look at many currently accepted practices as well as others like
lifestyle and diet interventions is necessary to fully inform us as to what the
most useful interventions truly are.
Work that you have done already should be included in some examination
of this sort. As you pointed out at
breakfast the first day, the evidence is there.
Let’s actually agree to look at it.
An evidence based practice is sound science in the clinical practice of
medicine.
How Evidence is Collected We
need to reevaluate how evidence is evaluated with regard to clinical practice
modalities. Whole practice outcomes
measures are what we need here. Again, I
know Richard Sarnat has done this already and it needs to be distributed and
evaluated in light of a cost savings approach.
I cannot agree more with Dr. Sarnat that we need to focus on the
ROI. It seems so simple, but we know
that there are economic disincentives for insurance companies to adopt these
approaches. To address this I believe
the conversation about regulation of the
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We need to address the
reverse
incentives in place for insurance
industries to actually deliver
less
costly healthcare.
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healthcare insurance industry should
start. Without their buy in, what we are
promoting will not happen. We have
striking evidence that a lack of regulation in the financial sectors has been
problematic. I believe we need to address the
reverse incentives in place for insurance industries to actually deliver less
costly healthcare.
This conversation may or may not also lead also to the regulation of
pharmaceutical companies, device manufacturers and hospitals.
Expand Primary Contact Provider Base We
need to mandate coverage for wellness and integrative medicine. It is not my opinion that allopathically
trained MDs are necessarily the best option for this job. We need to include other properly licensed
healthcare providers in the healthcare delivery model. It is becoming better accepted that diet and
lifestyle interventions are key to achieving lower incidence of chronic
diseases such as heart disease and diabetes.
There are many healthcare providers that already provide these services:
NDs, broad scope DCs, nutritionists, diabetic nutritionists, acupuncturists,
some nurses and nurse practitioners. We
need to reimburse them for those activities.
The conversation about this often devolves into a panic about increasing
the total healthcare expenditure. We
know already, but others will be enlightened by whole practice outcome research
and existing models of integrative clinics, that this approach will in fact
decrease overall cost. And, with the
shifting of resources from the high technology interventions not proven to be
safe, more effective, and cost effective there will be additional resources
available. We might actually save the
country money. How practical is that!
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A Valuable CPT Code
“When counseling and/or
coordination of care dominates
(more than 50%) the physician/
patient and/or
family encounter,
then time may be considered
the key or controlling factor to
qualify for a particular level o
f E/M services.”
-From Simon's colleague
Bruce Milliman, ND,
AMA's CPT Code
Advisory Committee
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Loan Repayment in
Washington State we have a program that reimburses a student’s medical school
loan burden in exchange for three years of primary care service in a rural or
underserved clinic. The providers
included in this program are MD, DO, ND, LPN, PA, Nurse Midwife, NP, Licensed Midwife,
Pharmacists and Dental Hygienists. This
is one practical way to incentivize the pursuit of careers in the front lines
of medicine and get service to those areas most in need. CPT
coding change. My colleague, Bruce
Milliman, ND sits onthe CPT coding committee and he is
responsible for the
following point. On page 8 of the 2009 CPT code book section on Evaluation and
Management (E/M) coding the following phrase concerning visit coding
exists: “when counseling and/or
coordination of care dominates (more than 50%) the physician/patient and/or
family encounter, then time may be considered the key or controlling factor to
qualify for a particular level of E/M services.” If the word “may” were
to be changed to “shall” then insurance companies could no longer deny those
counseling visits. That would provide an incentive for providers to spend
the extra time to have those life changing conversations. No additional
coding need be created to address this type of service.
 Bottom line: Without Bravewell, no IOM Summit
Comment: Simon's piece pulls out a series of points where we have structures in place to prompote integrative practice which are politically not used. First, we have technology assessments, for decades, going back to the Office of Technology Assessment for the US government which began suggesting, as early as 1978, that as little at 10%-20% of what is done in conventional medicine has quality cience supporting it. We don't ruthlessly use such assessment because we haven't the interests behind it, or a willingness to stand up to consumers who want anything, even if it kills them. Second, we could meet a lot of our primary care need if we expanded our national loan repayment programs included the list of practitioners in the Washington State program - and perhaps others (broad scope DCs? up-trained AOM practitioners?) yet the AMA and its allies politically step on this. Finally, as Simon's colleague Milliman has been pointing out for years, we have codes for humane, patient-centered, team care. They're just typically not covered by insurers.
As Simon, and the Summit, identify, have many of the ways to get there. Do we have the will?
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