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Is CAM Practitioner Use Down 50% Since 1997? NCCAM's Report on Costs of CAM and Visits: An Analysis PDF Print E-mail
Written by John Weeks   

Special Report: Is CAM Practitioner Use Down 50% Since 1997? An Analysis of NCCAM's Study of CAM Expenditures and Visits in 2007

Summary: Have total visits to CAM practitioners dropped by as much as 50% in the last decade? This is the suggestion from a report released July 30, 2009 by the NIH National Center for Complementary and Alternative Medicine and the Centers for Disease Control and Prevention. The report, an analysis of 2007 data from a survey of over 23,000 adults, is entitled "Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, 2007." The gross dimensions of consumer use remain eye-catching: $33.9 billion in out-of-pocket expenditures and 354 million visits to practitioners. Yet the authors also conclude that, as compared with Eisenberg's 1997 data on CAM use published in JAMA, total expenditures were almost flat and there was a shocking 50% downtrend in the number of visits. Are consumers turning away from CAM practitioners? How can this be with virtually all of these practitioner fields growing significantly? How do we make sense of these findings? Here is an extensive Integrator analysis of the potentially damaging outcomes from comparing these surveys.
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Big bucks out -of-pocket for CAM
1. Headlines in the LA Times, Boston Globe, Washington Post (and other papers) feature the $34-billion

Present on the July 30, 2009 press conference call when the
NIH National Center for Complementary and Alternative Medicine (NCCAM) rolled out their analysis of consumer use of CAM in 2007 were an assortment of media types. These included yours truly, as well as stringers for Associated Press and the Los Angeles Times, the Boston Globe and at least a handful of others who asked questions. The LA Times article that ran later that day deferred to the AP story. The headline was "Americans spend $34-billion a year for herbals, acupuncture, chiropractic, other alternative therapies." Similar AP stories ran in the Washington Post, the Globe and a few score other electronically available media, each featuring the gross dollars spent. Often they ran with the graphic, below, showing 44% of expenditures were for non-vitamin, non-mineral products, part of 65% for "self-care," with 35% representing practitioner services.
Courtesy: NCCAM/CDC


The lead-in to the AP article was that the $34-billion represents
"a 10th of (consumers) out-of-pocket health care dollars ... according to the first national estimate of such spending in more than a decade." The gross numbers in the study, entitled Costs of Complementary and Alternative Medicine and Frequency of Visits to CAM Practitioners: United States, 2007 are impressive. And the media was impressed. These were, largely, the story.

Gross Findings on Consumer Use of CAM in 2007 NCCAM Survey

 Category   Finding
Number of adults in the survey
Total out-of-pocket expenditures
  $33.9 billion
Total visits to CAM practitioners
  354 million
Out-of-pocket $ on practitioners
  $11.9 billion
Expenditures on CAM practitioners
as % of all out of pocket costs for
practitioner visits

The report's lead author is Richard Nahin, PhD, MPH,
acting director, Division of Extramural Research, and a senior adviser for scientific coordination and outreach with NCCAM. Nahin and NCCAM director Josephine Briggs, MD used the release to make the case for NCCAM's value. This was the refrain in the NCCAM press release, during the media event, and in a separate statement from Briggs on the NCCAM site.  Here is Briggs:
"With so many Americans using and spending money on CAM therapies, it is extremely important to know whether the products and practices they use are safe and effective. This underscores the importance of conducting rigorous research and providing evidence-based information on CAM so that health care providers and the public can make well-informed decisions."

2.   Deeper in the data: Is the consumer dissing CAM practitioners via a 50% drop in visits?

NCCAM's point was well-made, and widely disseminated in press accounts. This bodes well for NCCAM in its ongoing battle with its opponents who would like to see the Center terminated. The data argue loudly that this area deserves study. After all, NCCAM's $123-million is but 0.4% of the NIH's $30-billion allocation in 2009.

But this reporting glosses over suggestions in this report which may be viewed as unsettling and even shocking for those involved in integrative practice fields. The 2007 data contain findings that may be ammunition for CAM's opponents, if they are compared to data developed by Harvard's David Eisenberg, MD in 1997. Despite caveats that methods of the two surveys were different, Eisenberg's work, published in JAMA in 1998, is referenced on page one of the NCCAM/CDC paper. Comparisons are then and explored in some detail on page 4. 
If one chose to focus this report on comparative findings, here's how the headlines from this study could have run:

"Consumer visits to CAM practitioners drops 50% in a decade, expenditures flat"

Warning: All comparison by the NCCAM and in the rest of this article, is apples to oranges. Eisenberg used one methodology and instrument; the comparison data from 2007 data used a significantly different instrument and methodology.

Lead agency on the analysis
3. Side-note: Why NCCAM didn't simply replicate the Eisenberg survey

Obviously, a direct comparison to 1997, using the same instrument - even if not the same methods, since this was part of the larger CDC initiative - would allowed us to make cleaner comparisons. In a follow-up question to NCCAM after the press conference, I directly asked why NCCAM did not use Eisenberg's tool. Here is the response from Nahin:

"The 2007 NHIS was based on the 2002 NHIS. We wanted to be consistent between these two surveys. Dr. Eisenberg was on the advisory panel that helped NCCAM develop the 2002 survey, so the questions were initially more similar to his 1997 survey. The differences stem from the extensive pilot testing of the (CDC) questionnaire and changes done by the CDC."
That said, the comparisons were made, and they deserve some analysis, even if this exploration only leads to more questions than answers.

4.  Behind the headline not used: some unrefined comparative data

Some of what is clearly in, and out, of the NCCAM/CDC study, compared to Eisenberg's, clearly accounts for some of the differential and surprise. Yet first, some surprising comparison.


Comparative Findings on Consumer Use of CAM in 1997 and 2007 Studies

 Category  1997

Number of adults in the survey

Percent of adults using CAM

Total out-of-pocket expenditures
$33.9 billion
Total visits to CAM practitioners
 628.8 million

354 million
Out-of-pocket $ on practitioners
 $12.2 billion

$11.9 billion
CAM expenditures as % of
all out of pocket costs for
conventional physician services


One potential conclusion, if one accepts these numbers at face value: Consumers appear to be turning away from CAM practitioners in substantial numbers. Despite a decade of heightened marketing and visibility, total expenditures on CAM have sunk to no more than 1.5% of the nation's healthcare spending. Nahin and his co-authors go this far in the report:
"While some of the discrepancies (between the findings) may result from the different methodologies used in the two surveys, as well as the different types of CAM therapies queried, the 2007 (CDC-National Health Interview Survey) data suggest that a major factor in the (50%) reduction in visits to CAM providers in 2007 compared with 1997 was a decline in the number of adults who sought care from these practitioners and the frequency of visits."
Is the NCCAM data, compellingly sampled from 23,000 respondents, based on so different a study that comparisons should simply not have been made? Has there been this much of a down swing? Was the 1997 data from the Eisenberg study flawed? I will first look at a few hotspot areas where, in the words of NCCAM's team, significant "discrepancies may (have resulted) from the different methodologies."  

5.  Gross expenditures on CAM would have been $5-$10-billion higher in 2007 with different treatment of vitamins and minerals

In 1997, Eisenberg included a category entitled "megavitamins" as well as an herb category. This was his way of distinguishing between the therapeutic nutrition approaches of functional medicine practitioners, naturopathic physicians, life-extension doctors, broad-scope chiropractors and nutritionists, and the types of vitamins which conventional doctors have come to prescribe routinely. (Never mind, for a moment, that many of these now conventional practices of recommending vitamins were lambasted as useless alternatives 20 years ago.) Eisenberg's team estimated that $3.3-billion was spent on the "megavitamins" category in 1997.

The NCCAM/CDC, in this report, chose to limit this category to "non-vitamin, non-mineral." How much this shifted the study can be viewed in a couple of ways.
I asked my colleague and Integrator columnist Michael Levin, who often writes on natural products issues, for some data. He sent the following note, based on the annual estimated sales from the industry magazine Nutrition Business Journal:
"Using the NBJ data as a guide, VMS (vitamin and mineral supplements), which are out-of-pocket expenditures for the vast majority of Americans, probably represented another $10B in 2007. (The 2007 data, quoted below, reports the number to be $9.2B, but these numbers are probably under-reported due to the fact that sales from smaller companies are 'under the data collection radar.')"
By including all these vitamins and minerals, total out-of-pocket expenditures on CAM would have been closer to $44-billion, instead of $33.9-billion. This is $17-billion more than the $27-billion low-end of Eisenberg's estimate for 1997.

Following this line, the headlines in the Globe, the Post, the LA Times and other daily papers across the United States could have read:

"Expenditures on alternative medicine jump 63% to $44 billion in a decade"

Levin's estimated from NBJ was too high, according to natural products information service Natural Standard. In their August 4, 2009 newsletter account of the NCCAM report, the Natural Standard writers noted simply that the NCCAM estimate of total expenditures "does not include vitamin and mineral supplements, which account for almost $5 billion in annual sales." The writers did not note their source for this figure. Yet even at this level, the gross out-of-pocket expenditures would have been at $39-billion, or 44% higher than the $27-billion figure. 

6.  Did the exclusion of "megavitamins" diminish practitioner visit numbers?

By not looking at "megavitamin therapy," the NCCAM study may also have missed a significant number of practitioner visits. "Therapeutic nutrition," using diverse dietary supplements, is a significant component, as noted, in all naturopathic, whole-practice chiropractic, functional medical, integrative medicine, and anti-aging practices. Notably, the MD-oriented "integrative medicine" and anti-aging fields were each essentially birthed in the last decade, with both typically including prescriptions of significant numbers of natural products which began as "alternatives."
These are also widely prescribed by a significant subculture of unlicensed healers of various stripes who may have become "doctors" or "nutritionists" or "naturopaths" through mail-order programs. Because there is no category, these is no estimnate of related visits. Eisenberg's study associated megavitamins with 22-million visits in 1997.  

Courtesy: NCCAM/CDC


"Self-help groups" and other Eisenberg categories were not included in the NCCAM study

Because "CAM" is an amalgamation that is strange and shifting (for example, as above, a vitamin or mineral that was once "alternative" can later migrate and become part of "conventional" practice), the definition of what should be included in a survey like this is always challenging. Eisenberg's team, for instance, initially looked at "prayer" as an "alternative therapy" category, but then did not include those data among the 16 categories they reported in 1997.

Of Eisenberg's 16 categories, Nahin's group chose not only to leave out "megavitamin therapy" but also "spiritual healing by others,"
"self-help groups," and "folk remedies."  In 1997, these therapies were estimated to be used by 7%, 4.8% and 4.2% of those surveyed, respectively. These were the 5th, 7th and 10th top categories, from a use perspective. (Megavitamins was 6th.)

The impact of this NCCAM decision was even more significant than the exclusion of megavitamins on diminishing general use figures, as well as diminishing practitioner visits. In 1997, the self-help group category, which typically involves weekly, bi-weekly or monthly gatherings, was associated with over 79-million practitioner visits, based on an average of 18.9 visits annually per user.

If consumer use of practitioners for megavitamins and self-help groups had stayed even in 2007, another 100-million visits would have been added to the 354-million found. 

8.  The 2007 study treats yoga/tai chi/qigong as solely self-care, representing zero "practitioner visits

Perhaps one of the greatest areas of consumer uptake of an "alternative" practice in the last decade has been the emergence and acceptance of yoga-qigong-tai chi. A yoga group estimated that there were 70,000 yoga teachers and some 30-million people practicing yoga in 2005. These practices represent the second most significant CAM practice in US hospitals, according to a 2008 American Hospital Association survey In 2009, over 25,000 teachers and schools of these were registered with the Yoga Alliance

The impact of this categorization
of yoga-tai chi-qigong as only
self-care was substantial
on the
apparent decline in total
practitioner visits.

Interestingly, Eisenberg did not include these three individually or as a distinct category in 1997. Perhaps these mind-body approaches showed up under "relaxation practices" or "energy healing" or "spiritual healing by others." The report is not clear. What we do know is that the first two of these categories are linked to huge numbers of visits in Eisenberg's report: 103-million and 39 million, respectively. Nahin's group singles these alternatives out, reporting that "Yoga, tai chi, gigong classes" account for $4.1 billion of expenses and 12% of total out-of-pocket expenditures for CAM.

However, by choosing to report these as "classes," Nahin's 2007 team did not report any of these as "practitioner visits." In the press conference, I asked Nahin and Briggs why they made this choice, given the fact that people often have a health issue or musculoskeletal concern with which they are working with their Yoga/tai chi/qigong teachers. Briggs acknowledged that this was an area that could have been treated differently. Nahin shared their ultimately dominant view that most people use these approaches for health and wellness (self-care) rather than for treatment. Notably, the association of practitioners principally with disease care may be old paradigm thinking, and ultimately misrepresentation.

The impact of this categorization as only self-care was substantial on the decline in total practitioner visits. People who use teacher-therapists for stretching/exercise/movement meditation frequently go multiple times per week, or weekly. And many are stimulated to begin classes because they have some presenting ailment on which they are working, and on which their yoga-tai chi-gigong teacher/therapists consults.

If, say, 25,000 yoga teachers (30% of the number of teachers in the 2005 estimate) each teach an average of two classes per week of 20 students each, that would account for over 50-million additional "visits" per year.  Total visits to practitioners would climb, again, more closely to that 628-million figure estimated by Eisenberg. Now, if all the 70,000 yoga teachers estimated to be out there in 2005 averaged 2 classes a week with 20 students/clients each, the figure would jump by 140-million. This figure, added to those noted in #7, above, would put the visit total near 600,000, within 4% of Eisenberg's 1997 finding.

9.   What happened to 75% of those "relaxation technique" and "energy healing" visits in 1997?

The NCCAM study concludes: "The two practitioner groups that had the largest reduction in visits in 2007 compared with 1997 were practitioners of energy healing therapies (82% drop) and the various relaxation techniques (72% drop)." These two groups alone account for 50% of the dramatic decrease in visits since 1997. 

The NCCAM study links this decline to diminished use of practitioners among those who use these therapies, as well as huge reductions in average number of visits among those who use these techniques. Self-help books and related materials ascended in use. Just 9% used a practitioner for relaxation techniques in 2007, versus 15% in 1997. For energy therapies, the fall was 50%, from 1% to 0.5%. The decline in visits was more dramatic in these two categories: from 20.9 to 3.5 for relaxation and from 20.2 to 2.3 for energy therapies.

The very high visits levels in these categories in Eisenberg's 1997 data have always surprised me. What kinds of therapists might be offering these services? Were the visit numbers high because they included relaxation/energy approaches such as yoga-tai chi-qigong classes, which are "visit" intensive?  It is hard to not think something was haywire with the 1997 data.   

10.  Visits to licensed CAM practitioners: LAcs, homeopaths, NDs appear to show growth, DCs and massage down

The past decade has seen significant growth in the number of licensed CAM practitioners (chiropractics, massage therapists, acupuncturist, naturopathic physicians). Chiropractors, who have retained roughly the same number of schools, are graduating some 2000 new doctors per year, to total some 75,000 now in the field. The number of recognized acupuncture schools has jumped by roughly 20% to 61 today. Now there are over 8000 total students, with roughly a third of this number entering practice each year. The total number of licensed acupuncturists (LAc) jumped by over 40% to some 25,000 today. The massage field has also grown significantly, with the total number of schools reaching beyond 500. The small naturopathic medical profession has reportedly tripled in the number of licensed practitioners in the past decade. Meantime, the number of medical doctors practicing acupuncture has grown significantly, as has the number of so-called "naturopaths" and "nutritionists" who get mail-order degrees and cannot be licensed but practice many natural therapies. Was all this growth reflected in the comparative data?

Comparative Findings on Total Visits in Certain Practitioner Categories -
1997 to 2007

(in millions)

 Category    1997

* Includes osteopathic visits for manipulative therapy.
In general, the answer is no, the growth is not very well reflected. The exceptions are visits to acupuncturists, homeopaths and likely, to naturopathic doctors (many of whom also practice homeopathy, thus confounding the data).

NCCAM reported the trend upward in visits to acupuncturists as being a function of this being "a progressively more professionalized CAM provider group." The increased use is linked to increased licensing, greater media coverage and the growth, as noted, in the number of licensed practitioners. The movement of "naturopathy" into visibility (the Eisenberg team did not include the category in 1997) may be due to similar forces. However, the number of visits per user for acupuncture fell. The figure was 3.1 in 1997 and 2.42 in 2007. For naturopathy, the average number of visits was 2.0 in 2007.  Both visit numbers seem low to me, unless each field saw a lot of first-time triers who never came back, thus running down the average. This does not agree with what one hears from practitioners. 

Homeopathic practitioners apparently saw a near doubling of total visits between 1997 and 2007, to 3.4-million. However, the average number of visits dropped from 6.0 in Eisenberg's 1990 data, to 1.6 in 1997, and rebounded slightly to 2.0 in the NCCAM analysis. (Notably, homeopathic medicine was treated by NCCAM as part of the "self-care" category, totaling $2.9 billion, or 8.7% of all out-of-pocket expenditures.)  

The suggested decline in total visits for massage runs against expectation also, given annual surveys by the American Massage Therapy Association which show continuing increases in the percentage adults who use massage. A part is accounted through a decline in the visits per user, found to be 8.4 in Eisenberg's study and 2.16 in the NCCAM analysis.
Interestingly, the 1997 findings were down from 14.8 in Eisenberg's own 1990 data.

  For chiropractic, the rise in public
esteem of acupuncture, massage
and yoga may account for
some of the decline in visits.

All are newcomers in what was
solely chiropractic's space as an
alternative treatment for
musculoskeletal aches and pains.

For chiropractic, competitive pressures may account for some of this decline, if real. The rise in public esteem of acupuncture, massage and yoga are all viewed by many chiropractors as new practitioner types that have set up shop in what was solely chiropractic's space as an alternative treatment for musculoskeletal aches and pains. The NCCAM data suggest that visits per user fell even more precipitously for chiropractic. Eisenberg's finding was 9.8 in 1997, down from 12.6 in his 1990 survey. In the NCCAM report, all "chiropractic and osteopathic manipulation" (the category Nahin's group used) were used on average 3.45 visit per year.

I asked a colleague Michael Sackett, DC,
chief of staff/clinical internship department chair at Southern California University of Health Sciences what he thought about these numbers. He prefaced his remarks with "this is speculation, at this point" then stated that he thought that "3.5 visits might be it for those paying cash." He notes that the "tremendous infusion of managed care" in the last decade has driven down utilization patterns in chiropractic.

Interestingly, Sackett averages 6 visits per patient in his own practice for the main insurer for which he works. This is a use level that makes him one of the managed care firm's favored practitioners. Most chiropractors in the network average a higher number of visits per patient. This suggests to me that those outside the network may well have much higher visit rates, especially those with substantial numbers of workers' compensation and automobile injury patients.

In brief, while the trend line on visits per user is downward through Eisenberg's first study (1990) through his second (1997) and forward to the NCCAM report (2007), it is difficult to conclude otherwise than that some methodological difference accounts for the deep drop in the last decade.

11.  What about CAM services that are not paid out-of-pocket, but covered?

Eisenberg made an attempt to estimate the level of CAM services that were covered, as well as those that were paid out-of-pocket. NCCAM chose not to include covered services. Nahin was asked why in the press conference. He responded that when they were testing the questions in the survey, there was simply too much variation in response to feel any data could be valid.

Energy healing covered for 39%,
herbals medicines for 20%?

These levels of apparent coverage
in 1997
for such services did
not reflect
anything I knew. 
It would be nice to have something here, and the decision of Nahin's team also seems quite valid. The Eisenberg data has always seemed unbelievable to me, on this count. For instance, 39% said at least some of their "energy healing" was covered in 1997, 34% responded affirmatively on this question relative to their relaxation therapies and 20% on herbal medicines. Back in the mid-1990s, the core of my professional work was in consulting, writing and speaking on CAM coverage issues. I was used as an expert by the major national industry association and was contracted to organize the CAM sessions for the dominant managed care educator of the day, the National Managed Health Care Congress. I believed I knew the industry's relationship to CAM pretty well, and these levels of coverage for such services did not reflect anything I knew. 

The situation relative to coverage is even more complex today. There has been some increase in coverage of services by licensed CAM practitioners, particularly in the Northwest on in California, though overall coverage is relatively small, outside of chiropractic. We have also seen an increase in use of CAM therapies by conventional professionals whose services are otherwise covered, whether or not the insurer knows that the practitioner is delivering CAM treatment. Those surveyed might have a hard time answer appropriately as to whether the service was "covered." But the more confounding issue is the vast expansion of so-called "discount CAM products" or "CAM affinity products" by insurers. Under these, plan members can get a discount on the price of otherwise non-covered services. Is this "covered CAM"?

12. Concluding thoughts: Can interviewees be counted on to be able to count?

My analysis, suggests that Eisenberg's
method had high-side errors and the
NCCAM method tended low.

It would be interesting to see a
proper study of the two methods.

First, as I said earlier, more questions than answers come from this exploration.

While it was tempting for NCCAM to make comparisons, the researchers needed a good deal more caveating about their conclusions than was evident in the report. Perhaps Nahin should have stayed away from comparisons altogether.

For now, it would be intriguing to see what an independent group of professional data-miners and survey developers would say if the entire internal processes of these two studies were open to them. This is beyond my expertise. And these studies are deserving of this clarity. My analysis, above, would lead me to postulate that the findings of such an analysis would be that Eisenberg's method tended toward higher reporting and the NCCAM method tended low. I don't believe that we have actually seen anything like a 50% drop in visits to practitioners in this decade of cultural awakening to CAM. It would be interesting to know.

Second, two colleagues in the last two days, knowing I was writing on this subject, expressed an outsider's paranoia and wondered if NCCAM deliberately set up a survey methodology that would drive down utilization numbers. (If this is asked, then it would be reasonable to ask if Eisenberg deliberately set his up for the opposite.)

More questions than answers
come from this exploration.
While it was tempting for NCCAM
to make comparisons, they
needed a good deal more caveating
than was evident in the report. 

Still, I credit NCCAM for undertaking

the study, and Eisenberg, once
again, for his significant survey
contributions on CAM use.

While I disagree with some of NCCAM's choices, this is not my sense at all, based upon the content and tone of the study, of Briggs' statement, of the press-release or of the press conference. Nowhere did they intentionally highlight the significant apparent declines or the flat-growth. Of course, to focus on diminished utilization shoots NCCAM not in the foot but in the stomach. Perhaps those concerned about outing negative outcomes should be wondering about why I am highlighting them. Is Weeks on the take? I simply believe that the assertions in the 2007 report needed analysis.

Third, I credit NCCAM for undertaking the study, and Eisenberg, once again, for his significant survey contributions on CAM use. (The Integrator will also separately publish some of Eisenberg's comments on the NCCAM study.) Perhaps the confusion in outcomes is all bad karma from conventional researchers having tossed a huge array of practices, treatments and entire traditions into one swirling mass called "CAM." The effort to measure this loose gathering of still externalized practices, merged into one as "CAM" from origins all over the world, may be, from the perspective of conservative Western medicine, akin to sizing and managing the slow swirling cast-off material accumulating in the Pacific Ocean north of Hawaii. Good luck to those of us who seek clear dimensions.

Finally, as I think about the responders to the complex questions in these distinct research instruments, I think about a story retold by economist Paul Krugman in a recent New York Times column. He reports that a citizen - perhaps one of our respondents - while at a hearing on healthcare reform reportedly looked her US Senator in the eye and said, I paraphrase: Whatever you do, don't let government get its hands on my Medicare plan.

In such a population, with these unusual questions, the potential for significant margins of error is enormous. 

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