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:

• Forum on IOM: AMI's Richard Sarnat, MD, Leader in Integrative Business, Offers a Report and Musings
• Forum on the IOM Summit: Holistic Primary Care's Erik Goldman and JMPT's Claire Johnson
• Daphne White: Harkin Urges End to Discrimination Against Alternative Healthcare Practices

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.

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.

	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."

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 

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.

We reached consensus that there must be Inter Professional Education so that all health care practitioners can understand and refer to each other.

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, serv

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.

	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.

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

We need to address the reverse incentives in place for insurance industries to actually deliver less costly healthcare.

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!

	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

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?