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Reader Forum: Levin, Forbes, Rohleder, Calabrese, Stumpf, Holmes & Johnson on Integrator PDF Print E-mail
Written by John Weeks   

Reader Forum: Levin, Forbes, Rohleder, Calabrese, Stumpf and Holmes on Integrator Themes

Summary: A nice mix of themes and responses here: Michael Levin on the Seely-Herman research on cost savings of whole practice ND care for Canada Post employees; AHMA president David Forbes, MD on the NCCAM priorities; short notes on the Georgetown-Bastyr relationship promoted by Adi Haramati, PhD; Barney Holmes on biases relative to alternative medicine in Wikipedia; Carlo Calabrese, ND, MPH on what "CAM" fields have in common according to Wikipedia; Community Acupuncture Network co-founder Lisa Rohleder, LAc, and AOM educator Steven Stumpf, EdD on the incomes of licensed acupuncturists as reported by the National Certification Commission for Acupuncture and Oriental Medicine, plus a brief note from an anonymous naturopathic physician who believes that her profession has a similarly challenged economic perch. I comment on the link between Levin/Forbes and the income discussion.
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1.  Cost aficionado Michael Levin on the Seely-Herman  study of whole practice naturopathic care for cardiovascular disease

Integrator columnist Michael Levin has been urging the integrative practice community toward business models that examine cost outcomes and comparative cost offsets for over a decade. Here he comments on
Model Whole Practice Study Finds Naturopathic Care Effective, Cost Saving for Canadian Employer. Comments of 8 others on this study, run by Dugold Seely, NDF and Patricia Herman, MS, ND, PhD, are here
"I join other stakeholders in applauding the outstanding Canada Post study on CVD risk reduction by Drs. Seely and Hermann. Powerful! Demonstrating improved outcomes AND cost reduction resulting from with whole practice Naturopathic Care within 12 months is extremely significant,  particularly for public and private payers. Finally, we have a meaningful cost outcomes study! Kudos! 

"Now the real work begins.

"Once published, it will up to Naturopathic Business Leadership to leverage this work strategically to advance state licensure and reimbursement initiatives. Though I am no expert on the former, I'll gladly volunteer to help develop the positioning towards building consensus on the latter.

"My early work, in which I used the allopathic model of generic and therapeutic substitution as a 'Trojan Horse' to begin the mainstream integration of nutritional interventions ('use supplements instead of drugs: cheaper, effective and safer!') were steps one and two in a 'crawl, walk, run' strategy I envisioned for mainstreaming Naturopathy. The Canada Post study has the 'legs' to 'run.' Naturopathy has an opportunity to move this ball far down the field - let's not blow this wonderful opportunity! Let's run!

"Challenge: To improve the public health and advance the Naturopathic mission, a similar whole practice comparative study on managing metabolic syndrome is advised in the strongest possible terms. With current costs and trends, a significantly positive outcome is likely to be orders of magnitude more impactful than this landmark study on CVD risk reduction."

Michael D. Levin
Health Business Strategie
12042 SE Sunnyside Road
Clackamas, OR  97015
Comment: Levin has been banging this drum continuously as have a few of us who believe that the ticket to ride, or rather, to integrate, will be purchased via quality studies that show the economic benefit to purchasers (public and private). I hope the ND profession and other integrative practice fields will grab Levin's message into the core of their strategic beings.

Forbes: NCCAM needs to shift priorities
2.  David Forbes, MD: Holistic medicine leader on the NCCAM draft strategic plan

David Forbes, MD is the president of the American Holistic Medicine Association (AHMA). He writes as a follow-up to the draft Strategic Plan of the NIH National Center for Complementary and Alternative Medicine. The AHMA registered its initial views of NCCAM's direction last November; these were published in this article. Forbes added these comments.
"I read with interest and enthusiasm the NCCAM Report.  I believe our goals at the AHMA are much as you laid out in your analysis and recommendations

"In particular I am heartened by the improved focus on outcomes research and emphasis on wholeness and prevention.  However, I was less than enthused to see the priority listings remain focused at the top on old-school, reductionist research.  I wholeheartedly agree that the prioritization should be shifted.  As the priorities go, so shall the money. 

"Hopefully this is the appropriate beginning, and we will certainly continue to exhort NCCAM to move the outcomes-oriented research focus higher on the priority list and spend less and less time distracted (as you very aptly named it) by an approach that has limited utility for the subject with which they are tasked."

David Forbes, MD
President, AHMA
Comment: The integrative/holistic MD world has mainly been characterized by a gown/town split. The holistic doctors are not typically in ivory towers and therefore in the real world and closed to real-world outcomes, such as Forbes advocates targeting. Interestingly,

Adi Haramati: The agreement he brokered is celebrated
3.  Quick notes of enjoyment on the Georgetown/Bastyr inter-program relationship

The article on the pioneering, respectful relationship established between the MS Physiology/CAM course at Georgetown University and the naturopathic medical program at Bastyr University stimulated a few brief bursts of enjoyment with this move toward inter-professional and inter-institutional academic respect. (I mention no names as I didn't secure consent to note their comments.) A healthcare journalist wrote: "How wonderful!" An early hospital-based integrative medical doctor wrote:
"This is wonderful, John! Thanks. I'm feeling hopeful once again." The good work of the Georgetown and Bastyr leaders apparently gave me some reflected virtue. A leader in the Oncology Association of Naturopathic Physicians simply responded to the Integrator publication with: "As always, excellent info." And a medical doctor/researcher sent a note that read: "A thousand thanks John for all you do for the field."
Comment: Integration advances such as this between Georgetown and Bastyr do breed hope, and that puts a refreshing blush into the faces of those pushing that boulder. How does Vidal Sassoon put it: When you look good, we look good. I do enjoy being complemented for my passing on the good work of others!

4.  Barney Holmes: Wikipedia's anti-authority stand led to many of the same authorities taking over 

Reader Barney Holmes' primary interest in integrative health stemmed from explorations of non-drug treatments for mental health conditions. This led him to a conflict with Wikipedia (WP) and to this comment on the article in the October 2010 Round-up on what some are finding is an anti-CAM bias on Wikipedia.
(See Alliance for Natural Health takes on Wikipedia over biases against natural medicine.)

"I saw your comment on NaturalNews and read your article on WP. You can see my views here. Some of that page is angry but that's because I was hurt by the shabby nature of many of the 'editors' who have co-opted WP.

"WP still has some good articles but it's over for me. I saw the same thing as you in the mental health field. I got access to my local university library and that really shocked me because of what I found. Hundreds of thousands of references and papers, journal entries and studies about non-drug and natural treatments for the so called 'mental illnesses' making a complete mockery of any WP claim to NPOV [no point of view]. Many still come back with the 'you just have to put in references' but, of course, they are simply removed usually with a 'low quality reference'[ response. Of course the simple truth of the matter is that no reference will ever be good enough on certain articles.

"I blame this all on a simple breakdown of commonsense in the way WP is run. It became so anti-authoritarian that it was afraid to assert it's own authority - ironically this eventually let in the authorities it was trying to keep out."

I hope Citizendium will have more commonsense.


Barney Holmes
Holmes wrote back later: "I've been checking out Citizendium and it looks interesting. Votes are there which of course were frowned upon at WP. I'll join up when I get to it and jump in. I guess the trick is balance as always. Not too much control, but not too much freedom without oversight."

Calabrese: What Wikipedia says on CAM commonalities
5.  Carlo Calabrese, ND, MPH on what Wikipedia says about commonalities between the CAM fields

Carlo Calabrese, ND, MPH is a close colleague in various capacities including our work with the multidisciplinary Academic Consortium for Complementary and Alternative Health Care (ACCAHC). With ACCAHC, we have had a running exchange on just whether and why these so-called "CAM" disciplines  belong in the same room. After all, the differences in maturity, in policy involvement, in inclusion in the payment system and in various philosophic areas between chiropractic medicine and naturopathic medicine and acupuncture and Oriental medicine and massage therapy are significant. Calabrese happened across the following under "alternative medicine" in Wikipedia, and sent it on to me:
"Some researchers in alternative medicine oppose this grouping [CAM], preferring to emphasize differences of approach, but nevertheless use the term CAM, which has become standard. Although heterogeneous, the major CAM systems have many common characteristics, including a focus on individualizing treatments, treating the whole person, promoting self-care and self-healing, and recognizing the spiritual nature of each individual. In addition, many CAM systems have characteristics commonly found in mainstream health care, such as a focus on good nutrition and preventive practices.
Comment:  This seemed a good pairing with the comments from Barney Holkmes, above. The "grouping" of roughly 7 zillion therapies, providers, disciplines, systems, practices and etc. leaves everyone involved knowing at times that they most certainly do not want to be a member of this club that is willing to include them. Yet the statement of commonalities in this disputed commons of Wikipedia is worth reflection, and appreciation: " ... a focus on individualizing treatments, treating the whole person, promoting self-care and self-healing, and recognizing the spiritual nature of each individual." This, plus "a focus on good nutrition and preventive practices." Heck, maybe I do want to be in this club. Thanks Carlo. 

Rohleder: Challenges the AOM institutions
5. Community Acupuncture Network's Lisa Rohleder, LAc respond to Integrator article on AOM incomes

The co-founder of the Community Acupuncture Network Lisa Rohleder, LAc has focused a part of her significant energy on getting the AOM profession to look squarely at the actual level of opportunity AOM graduates presently have to earn a living. Rohleder saw the Integrator article on the NCCAOM findings on average incomes and posted her own response on the CAN blog. She writes:
"I'd like to start by looking at the two basic business models that together make up 'the acupuncture profession". No, I don't mean the boutique model and the community model. I mean the business model that is built on selling the fantasy of being an acupuncturist, and the business model that is built on delivering acupuncture treatments to real patients."
Rohleder focuses here, as elsewhere, on the difference in incomes between individuals working in the schools and  those working to make a living fully as practitioners. Rohleder then called my attention to two other CAN blogs on the school-practitioner relationship, including the practice of schools earning money administering student loans. They ask whether or not a school has any responsibility for the practice success of their graduates. The tow blogs are here and here

Stumpf: AOM students not making enough to pay debt
6.  Steven Stumpf, EdD on the subject of AOM incomes as reported in the NCCAOM survey

Steven Stumpf, EdD is a former AOM school administrator who has recently written on workforce issues relative to the AOM profession. He had published two papers:
Mainstreaming Acupuncture: Barriers & Solutions and Unveiling the United States Acupuncture Workforce. Stumpf also responded to the Integrator article "Financial Challenges and Warning Labels. Stumpf's website is here.
"Good column for introducing your readers to an incredible reality. I have been writing on this subject for more than 3 years. I am thrilled it is finally getting some attention. The discussion can go much deeper as the numbers posted are the best case scenarios. Where did the BLS get their median data?

"Take the debt issue...How much income is required to pay back $45,000 in 10 years (Title IV proposal) when payments are limited to no more than 8% of income? A licensed acupuncturist would need annual earnings of $56,250 to meet these criteria. The NCCAOM reported in 2010 that 70% of LAcs earn less than $60,000. [Editor's note: This figure is gross, not net.] The median (mid point in the distribution) has to be lower than $60,000 and in all likelihood it may be quite a bit lower than $56,250. We believe the median LAc income may be closer to $35,000. In the best case half of all LAcs are unable to pay back their loans. In the worst case that figure may be 70%. The schools from which these LAcs graduated are at risk of losing the primary source of their revenue.

"Your interview with Dr. Ward-Cook could have been much sharper. Why did she release the data in the August AT [Acupuncture Today] article 6 months behind the initial release of her report? Why were these graphs not included in  the 2010 report? The conclusions on the % of LAcs earning less than $20,00 are shameful.

"We can only speculate on what is the % of all LAcs making less than $20k/yr. The Gross Income graph (AT August) breaks out P/T and F/T. ~45% of the P/Ts are making less than $20K. ~9% of F/T make less than $20K. It looks like ~45% of F/T make less than $60K. The combined % at this level is 70% (as originally reported). Clearly, the P/T LAcs are doing far worse than the F/T and the P/T account for 60% of ALL LAcs.

"The best estimates we have for COMBINED LAcs (F/T plus P/T) are in the third graph: "Percent Diplomates in <$20,000 Category." The 3 states with the largest numbers of LAcs are, in order, CA (~33.5%), NY (~12%) and FL (~7%). WA and CO are almost the same as FL.

"The numbers making less than $20,000 in each state, respectively is.... 37% (CA), 42.5% (NY), 34.6% (CO), and 26.2%% (FL) and 15.7% (CO). We assume these data combine F/T and P/T as they are all diplomates. Notice that Ward-Cook reports these as the states with the highest response rates. As you can also see these are the states with the highest numbers of LAcs. I do not think this is another attempt to obfuscate. Just sloppy work. Keep in mind these five states account for more than 60% of all the LAcs in the nation.

"Summing it up...about 45% of all the LAcs in the country are in two states: CA and NY. Roughly 40% of the LAcs in these states make LESS THAN $20,000.

C"O, WA and FL account for about 17% of all the LAcs in the nation. Roughly averaging their combined percentages about 1 in 4 make less than $20,000.

"Put it all together and about one in three of 80% of all LAcs make less than $20,000."

Steven H. Stumpf, Ed.D.

Comment: In the absence of hard data, we have guestimations, such as these asembled by Stumpf. (Rohleder also does a useful job of extrapolating from time-to-time in her columns.) Stumpf does not speak to the very important reality that the original NCCAOM data capture gross. What is the range that an LAc nets versus gross? Probably 40%-80%, and likely in the 60%-75% range, is my guess (or $36,000-$45,000 net on $60,000 gross). Thus if Stumpf's #s are in the ballpark that the median "income" (actually "receipts") is "closer to $35,000," then we are talking an actual media NET income OF $21,000-$25,000. As one follows Stumpf into the lower ranges, we move into what in this Halloween time of year must be called a ghoulish realm.

6.  Anonymous naturopathic doctor on the data on AOM salaries

I received this message from a reader who did not want to identify herself: "
The situation is just as (or more) dismal for ND's. Do you know of any similar surveys which have been done for the naturopathic profession?" The most recent data from the naturopathic profession was from a 2004 survey by the Association of Naturopathic Medical Colleges.


Overall Comment: Do any of you see a link between the comments of Levin and Forbes and the discussion of problematic economic futures for licensed CAM practitioners? My (strongly held) view is that the lack of "real world outcomes" - for which Levin and Forbes advocate - effectively keeps the door slammed on these disciplines' entry into a healthcare system that costs some $2.6-trillion but leaves them broke. It is challenging for me sometimes to not think that the lack of research on these disciplines, though such real world research was directly advocated by Congress in NCCAM's mandate, is just one more example of the dominant school of medicine using tools it has effectively owned (research methods and NIH funding) to hold down others.

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