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8 Voices: Stakeholders on Report of Employer Cost Savings from Whole Practice Naturopathic Care PDF Print E-mail
Written by John Weeks   

8 Voices: Stakeholders on Seely-Herman Report of Canada Post Savings from Whole Practice Naturopathic Care for CVD

Summary: Readers from multiple stakeholders in integrative medicine responded to the findings on integrative naturopathic medicine entitled "Model Whole Practice Study Finds Treatment by Naturopathic Doctors Effective & Cost-Saving for Canada Post Employees with Cardiovascular Disease." The project, led by Dugald Seely, BSc, ND, MSc and Patricia Herman, MS, ND, PhD, was quickly recognized as useful in outreach to employers, policy makers, the mainstream delivery system and clinicians themselves. Some readers merely exulted. Here are comments received from university president James Winterstein, DC, employer consultant Chris Skisak, naturopathic oncology specialist Chad Aschtgen, ND, FABNO, hospital COO Richard Gannotta, NP, DHA, FACHE, North Carolina licensing leader Susan Delaney, ND, holistic doctor Kjersten Gmeiner, MD, Israeli hospital mind-body coordinator Nimrod Sheinman, ND and Foundations Project director Pamela Snider, ND.
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Care proved effective and cost-effective for firm's employees
Publication of this report on whole practice research on integrative naturopathic medicine (Model Whole Practice Study Finds Treatment by Naturopathic Doctors Effective & Cost-Saving for Canada Post Employees with Cardiovascular Disease) provoked a wide array of positive responses, from around the US and from South Africa and Israel, and across multiple stakeholder representatives. Do you have additional perspectives? How might this study have been better organized? What are the other applications for a model like this? 

Winterstein: Long involvement in outcomes research
1.  James Winterstein, DC: "Yes!"

Jim Winterstein, DC, is president of National University of Health Sciences in Chicago, a multidisciplinary institution with programs in chiropractic medicine, acupuncture and Oriental medicine, naturopathic medicine and massage therapy. (See Integrator feature on NUHS here.)  Here was Winterstein's immediate response on reading the article:
Comment: Winterstein has earned a right to such brevity and enthusiasm. Through his work as a board member of Alternative Medicine Integration Group, an Integrator sponsor, Winterstein has played a leadership role in generating 2 of the most interesting and potentially useful practice outcomes sets in all of integrative care. One is the AMI pilot with HMO Illinois that found significant cost savings in an integrative primary care model and the second an integrative pain pilot project under a waiver with Florida Medicaid that includes services of licensed massage therapists and acupuncturists in a holistic nurse-managed care plan. "YESSSS!" captured my own response exactly. Why aren't we doing more of this work?

Skisak: Useful in reaching employers
2.  Chris
Skisak: "(For employers) only those who support their methodologies with empirical data will survive ..."

Christ Skisak is president of Houston-based Corporate Health Management Solutions
which he describes as "an organizational health and productivity management company." The firm provides employers and their health management suppliers "with strategies and software tools to improve workforce health and demonstrate its direct link with business financial performance." Skisak and I have been in contact for several years, as he notes, typically when he is in need of evidence to support an economic case he wants to make to an employer relative to integrative care.
"I was pleased to see this type of research linked to CAM methodology.  I remember asking you several years ago what types of controlled CAM studies existed. The answer then as now is the same: very few. 

"This is a step in the right direction.  I chair the Houston Wellness Association's Worksite Wellness Committee.  I find that employers still approach health care with a bottom line cost mentality [focusing on how much a policy costs] rather than an outcomes based approach [the value from the type of policy]. This will not change until insurers, brokers, and employers have the data to support the ROI of traditional and CAM modalities. 

"I am working toward the development of an employer/provider data consortium in Houston. The intent will be to benchmark integrated metrics. These will include absenteeism, presenteeism and healthcare costs associated with general and chronic conditions. Cohorts who are and are not participatory and compliant with specific health promotion and disease management initiatives will be compared. I think this type of approach which is similar to that of the Michigan Health Management Research Center will be essential as more and more traditional and non-traditional medical practices are introduced as ways to save cost and improve business performance.  Only those who can support their methodologies with empirical data will survive."

Comment: If anyone wonders why I continue pressing NCCAM to push an outcomes agenda, it is the plaintive requests from people like Skisak who work to get an employer's ear then face the near wasteland of data amidst a plethora of claims. People like Skisak need to be armed.

Gannotta: Useful for clinicians and mainstream delivery decision-makers
3.  Hospital COO Richard Gannotta, NP, DHA: "Seely, Herman study is significant ..."

Rick Gannotta, NP, DHA recently published a report in the Integrator
entitled Perceptions of Medical Directors and Hospital Executives Regarding the Value of Inpatient Integrative Medicine Programs. Gannotta is COO of the Duke Raleigh Hospital. I asked him for his perspective on this report.
"The Seely-Herman study is significant. The incorporation of the cost effective modalities employed [in this study] should be seriously considered by all whole medical systems practitioners.

"In this case the fact that the study looked at treatment by naturopathic doctors, and the measures analyzed - clinical and cost outcomes - should be a signal to all integrative medicine researchers that the focus on cost effective treatments will further advance the incorporation of integrative medicine into the mainstream healthcare delivery system."
Comment: Gannotta's initial comment goes to the core of what good research advances: practice betterment. In the case of the naturopathic medical care captured by Seely and Herman, the recommended practice change for those at risk of CVD is toward a whole practice that focuses heavily on habit change. Echoes of Skisak's perspective can be heard in Gannotta's second comment. If integrative medicine researchers want to advance the incorporation into mainstream delivery system, Gannotta suggests, from his perch inside a hospital, the Seely-Herman methodology is a direction to consider. I do wonder at how many degrees of separation much research is from opening more options to human beings inside the mainstream delivery system.  

Delaney: Useful with legislators
4.  Susan Delaney, ND: Immediate value in pushing licensing legislation for NDs

Susan Delaney, ND practices in North Carolina where she has been engaged in the Sisyphisian task of pushing for a licensing law for her profession for roughly 2 decades. That's a lot of times to roll legislation up the actual Hill only to have it rolled back down at sine die every 2 years, then start over again. Delaney responded immediately from the heart of that work: 
"I just saw the article you did on the Canadian study with whole practice naturopathic care. I was at that session [at the conference] and felt the excitement you obviously do as well. I anticipate that it will be of great value in our work for licensing. Thanks."
Comment: So, we have perspectives from respondents that these types of outcomes will be good in outreach to employers, in decisions regarding integration into the delivery systems, in bettering the care delivered by practitioners and here, in potentially moving public policy decisions of legislators. This is a powerful set of stakeholder that one set of outcomes may directly influence. Aschtgen, below, underscores this point and suggests some next steps for such a research strategy.

Aschtgen: Many applications for these research methods
5.  Chad Aschtgen, ND, FABNO: Other chronic disease areas where methods like these might be replicated

Chad Aschtgen, ND, FABNO is a Seattle-based naturopathic physician who works out of one of the city's most significant integrative medicine facilities, the Institute of Complementary Medicine. Aschtgen is an integrative oncology specialist and also works out of Providence Integrative Cancer Care in Olympia, Washington.
"I quite agree with you; this type of research and these data are critically important as we continue to move forward in advancing the naturopathic profession and broader discipline of integrative medicine.  The preliminary data from the Seely/Herman study certainly is something to be excited about and we should all look forward to seeing the final analysis as it gets published.  Provided the ‘punch line' sticks, this research has the potential to really catapult our naturopathic community efforts forward in so many arenas- further scientific research, institutional and organizational collaborations, third party payments, state and federal policy and more.

"To your suggestion of 'a dozen such... studies,' I will look forward to seeing how the Naturopathic Physician Research Institute (NPRI) will facilitate exactly this within the ND community. Although I am not a research scientist, rather a clinician, I too expect that this type of study would be fairly easy to emulate with numerous other conditions. Consider COPD and asthma, the fourth most common cause of death in the United States, and diabetes, number six for mortality. Arthritis, kidney disease, pack pain and hypertension are among the top ten most costly diseases in the U.S. and would be amenable to such study. Although the research approach would likely require more notable modifications, I would like to believe that similar inquiry regarding integrative care with various cancer diseases and oncology treatment would also prove an area of improved clinical, financial and/or quality of life outcomes.  Of course I have yet to mention what many consider to be a mainstay of naturopathic care, the varied aspects of gastrointestinal health!"
Comment: Yes, we do need to see the final, published study, as both Seely and Herman noted in their presentation. The present data are preliminary. As a board member with NPRI, I am doing what I can in that field to support the group of scientists we have convened to foster just the kinds of studies Aschtgen recommends. The key element may be in finding an employer and/or union that will respond to these data and be game to pilot something with their employees. I'm betting some of you have employer decision-makers in your networks.

Gmeiner: Pleased
6.  Holistic doctor Kjersten Gmeiner, MD: More pleasure in the news ...

Kjersten Gmeiner, MD is a past board member of the American Holistic Medical Association. She was featured in  the Integrator talking about the fit of "group visits' with holistic practice.
"TERRIFIC!!!!!!!! thank you for sharing!!!!!!!!!!!!"
Comment: After Gmeiner sent me this, I asked if I could publish it just as I had asked Winterstein, above. I comfortably project in both cases that pent-up demand propelled these gusts of enthusiasm for this Canadian College of Naturopathic Medicine/Canada Post/Canadian Union of Postal Workers project.

Sheinman: Sent me by my hospital boss
7.  Nimrod Sheinman, ND: Mind-body leader in Israeli hospital has report forwarded to him ...

Nimrod Sheinman, ND is a National College of Natural Medicine-educated naturopathic physician who completed a residency at Bastyr University in the late 1980s before returning to Israel where he currently works in a hospital-based integrative medicine program. He wrote:

"Your name appeared uninvited today in my e-mail box, through your recent report on the naturopathic contribution to postal workers in Canada. The report was sent to me by my 'boss' at the integrative medicine department, Davidoff oncology hospital, Rabin Medical Center where I'm head of the mind-body unit. Nice to hear from you!"
When I wrote back to Sheinman, he noted that his "boss" is Opher Caspi, MD, PhD one of the first fellows who came through the program at what is now the University of Arizona Center for Integrative Medicine. Caspi runs integrative medicine at the Davidoff oncology hospital.
Comment:  A pleasing sign of the impact of the Seely-Herman work is that an integrative medicine leader from across the great water sent the link out to his staff, even if that staff member happens to be a naturopathic physician. (It was also pleasing to be put back in touch with Sheinman, with whom I hadn't communicated in the better part of a decade. Thanks Opher.)

Snider: Counterweight to the preponderance of single agent evidence
8.  Pamela Snider, ND
: Corrective role of whole practices research for science-based natural medicine

Integrator adviser Pamela Snider, ND, executive editor for the Foundations of Naturopathic Medicine Project, sent a comment which touched on the relationship between this whole practice research and the naturopathic profession's drift toward "green allopathy" - the first line use of natural drugs. Snider referenced a description of Joseph Pizzorno, ND in the Integrator coverage of the 25th anniversary convention of the American Association of Naturopathic Physicians.  I had written that Pizzorno's elevation of the concept of "science-based natural medicine" has stimulated the tendency among new naturopathic physicians toward focusing care on supplement prescriptions. Snider wrote:
"Joe has always been opposed actually to the overemphasis on ‘green drugs.' It's an indirect effect of his support for science based natural medicine.

"The [presently available]
CAM/natural medicine research content is highly reductionist. The greatest percentage of this research falls into the ‘green drug' category, sad to say. It looks at a single green agent for a symptom or a conventional disease classification. So, without working our tails off to operationalize the soul of this medicine by researching what we actually do, voila.

"The allopathic drift begins with a drift to green drugs. Practitioners go where the ‘evidence' is. This is why Dugald's research is so critical, and Patricia Herman's. This is why NCCAM needs to fund a wider array of research approaches such as the AANP, the Association of Accredited Naturopathic Medical Colleges, the Academic Consortium for Complementary and Alternative Health Care, the Consortium of Academic Health Centers for Integrative Medicine and others have advocated. This is why the Naturopathic Physicians Research Institute is a vital part of the landscape."

In an integration dialogue shaped
by evidence, many welcome this
counter-weight to
dominance of the data

of reduction and suppression.

Comment: Snider speaks to my favorite research-clinical conundrum. It is an ugly one, if simple. If a clinician can locate an exceptionally powerful evidence base on how to suppress the symptom of a condition with a drug, but has at best suggestive data on how to help the patient create health when living with that condition, what is the best, evidence-informed path to take?

While I typically frame this conundrum around pharmaceutically-funded and well-researched conventional pharma therapy versus a whole person protocol to help create health, Snider presents it wholly within a natural health context.

Part of the exultation in receiving these outcomes is escapist: In an integration dialogue shaped by evidence, many welcome this counterweight to the dominance of the data of reduction and suppression.

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for inclusion in a future Integrator.

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