Cost and Economics of Integrative Healthcare in 2010: 25 Brief Articles
Written by John Weeks
Cost and Economics of Integrative Healthcare in 2010: 25 Brief Articles
Summary: A review of 2010 Integrator content found 25 articles that directly relate to cost and economics issues. Medicare. Duke's personalized program. Direct access to chiropractors in Blue Cross Blue Shield of Tennessee. CAM practitioners and Washington state insurers. Medicaid. Non-discrimination. Ornish and Pritikin in Medicare. Sebelius' views. Business viability for licensed acupuncturists. Whole practice naturopathic care for Canada Post employees. Supplement sales. Allina's in-patient program. Massage practice trends. Some of the 24 report research studies, others policy action, some marketplace reports. The articles are gathered here with links to primary sources. I follow with brief commentary.
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The research that will make the most difference in the uptake of integrative practitioners and approaches into the United States' $2.6 trillion payment and delivery system is that which examines costs and cost-offsets. The highfalutin notion of transforming our healthcare system is inextricably linked with this lower chakra work. Employers, government agencies and hospitals continuously ask what will this cost them. Or, conversely, can you show me this will save? Or, bluntly: What is the business model that supports integration?
Prime mover in integration decisions
Yet while getting-and-spendingmay be too much with us in Wordsworth's world as in the world of leading stakeholders in payment and delivery, the research stakeholder focuses its own getting and spending of major grants on what they consider higher gods: basic research and efficacy trials. Cost questions are lower dogs.
The result, to abuse Wordsworth, is that the world, alas, is not enough with us in integrative health care research, despite the wishes framed in the NIH's mandate. After 15 years of "integrative medicine" and "complementary and alternative medicine integration," employers, government agencies, hospitals and health systems continue to brush back inclusion of unconventional, whole person approaches for fear of what this will cost them.
To bring cost information to the surface, the Integrator routinely reports news from the economic front of integrative health care. While reviewing the 2010 year of Integrator content for the Top 10 lists, I began a list of cost, economics and business model-related articles. I was intrigued with the list and thought some of you would be too. It's still slim pickings. Here they are in the form in which they were reported, typically, in one of the monthly Integrator Round-ups.
If I have missed anything of significance from 2010 that belongs here, let me know and I will publish it in a future Integrator. I offer a few comments at the end.
_____________________________
January
Rich rewards from integrative health care
George Institute/Allina inpatient initiative reports $2000 savings per patient in integrative care program
In an interview with Natural Medicine Journal, Lori Knutson, RN, BC-HN, executive director of the Penny George Institute
reports that a preliminary analysis has found that the inpatient
integrative care initiative is saving $2000 per patient per hospital
stay for patients at Abbott Northwestern Hospital, part of the Allina
system. Knutson adds that this includes administrative costs. Her report
followed a question from NMJ publisher Karolyn Gazella in which
she asks whether the initiative, with over 60,000 inpatient visit since
2004, can legitimately be considered a model for the nation, a statement
in the Integrator
when Knutson was honored among the Top 10 for 2009. Knutson noted that
to be rolled out as a model, the hospital's positive clinical outcomes
will not suffice: "[Becoming a model] goes to the financial piece. This
is where you get the ear of legislators." Knutson notes that a critical
need in offering these data is to have "the comparative effectiveness
research and health services funding to support the research and tell
the story." Knutson believes that the value of Allina as a model rests
on an integrated approach to policy
Comment: Gazella's 20 minute interview
is a nice synopsis of this significant initiative which is significant
both for offering outcomes on an integrative approach to care and also
for outlining what Knutson call an "integrated approach" to policy
change. Here's hoping that research funders of all kinds will see the
potential value in this model and make sure appropriate funding is in
the hands of the George Institute, and any similar models, to look at
this every way we can.
Duke program saves, but not backed
Duke Prospective Health reports annualized $2200 per employee per year savings from integrative approach
The personalized, prospective healthcare model tested at Duke Prospective Health
in the Duke University Medical System is showing significant benefits
in lowering employee costs according to a report referenced in a recent JAMA column, Improving Health by Taking it Personally, written by Ralph Snyderman, MD and Michaela Dinan, BS (JAMA. 2010;303(4):363-364).
The approach to patient care includes a health risk assessment, setting
of personal health goals, health coaches, primary care providers and
some disease management services. A report on the Duke site referenced in the column shares these outcomes:
"During the first two years of Prospective Health, individuals in the high-risk group, people who o typically have the highest medical costs, had a 3.5 percent decrease
in medical costs. This saved hundreds of thousands dollars in expenses
for the health insurance plans paid for by Duke and employee premiums.
"Ironically, because reimbursement
compensates
in-hospital patient
care at a higher level than outpatient
services,
the health system realized
a financial disadvantage, and the
program
proved economically
unsustainable."
"Duke has also seen reductions in the number of emergency room visits
and the length of hospital stays during the first two years of the
program. Such indicators are helping Duke keep its medical costs, and
thus its premiums for health insurance, well below national and
regional trends. For example, last year, Duke's average health care
cost per employee was $5,298, compared to the national average of
$7,498, according to Hewitt Associates, a Human Resources consulting
firm."
Snyderman and Dinan used the JAMA column
to push insurance reform: "Personalized, prospective approaches to
health will not be attainable without reimbursement reform to support
them." They noted a problem with reimbursement in an earlier pilot. In
that case, with 117 patients with congestive heart failure, $8571 per
patient in costs were avoided. They note: "Ironically, because
reimbursement compensates in-hospital patient care at a higher level
than outpatient services, the health system realized a financial
disadvantage, and the program proved economically unsustainable.
Comment: The key elements of the Duke
model of care are well integrated into the best integrative practices,
whether integrative medical, functional, naturopathic, chiropractic, TCM
or holistic nursing. If we are to "attain" these approaches for most of
the population, the onus is on those who do so to generate outcomes as
Duke Progressive Health has accomplished. And this puts the onus on our
research community to wake up to this need, ask the right questions and
make the funding available.
Mixed report on coverage of expanded chiropractic care
Major Medicare demonstration project on expanded chiropractic
coverage finds huge variation on key "cost neutrality" measure
In 2003, the American
Chiropractic Association (ACA) took a
bet with Medicare that expanded coverage of chiropractic services would
be at least cost neutral for the agency. In January 2010, HHS Secretary Kathleen Sibelius
submitted her final report to
Congress on the 2005-2007 demonstration project that Medicare began
following the Congressional mandate. Patients rated the
pilot highly across the board. Yet cost results were radically
different, based on location. In the demonstration's New Mexico, Maine
and Virginia sites, the expanded coverage was cost-neutral or better for the
global neuromuscoluskeletal (NMS) costs that were measured. But in the 4th site of
Northern Illinois, where 2/3 of the dollars were spent, Medicare showed
losses of $50-million. Now Medicare is
looking to recoup $50-million through a lowering of reimbursement rates
for chiropractors.ACA formed a team including
health services expert
Christine
Goertz, DC, PhD and the ACA's Medicare coverage expert Susan McClelland to
explore the huge variances between sites. The biggest question: Why is
the
Chicago
area such a costly outlier? There is no indication now when the ACA
examination will be complete. Meantime, ACA is opposing the
reimbursement decrease. An Integrator article including interviews with
Goertz, McClelland and others is published
here. The ACA maintains a resource page on the project here.
Comment: The lessons and process here
may be of
interest to any integrative practice interests who believe all they
need is a demonstration project to guarantee rapid adoption into
the healthcare payment and delivery system. One salient feature: Like
the mandate to the NIH to establish the National Center for Complementary and
Alternative Medicine, this demonstration also came from Congress
rather than from within the affected agency.
February
NIH Office of Dietary Supplements mounts workshop on economic analysis of nutrition interventions
"Despite the rapid escalation of healthcare costs,
research into healthcare economic solutions has not taken center stage."
So runs the copy in an announcement of a February 23-24, 2010
workshop that will be sponsored by the National Institutes of Health
(NIH) Office of Dietary Supplements (ODS),
the National Center for Complementary and Alternative Medicine (NCCAM), the
National Cancer Institute (NCI), and the National Institute of Nursing Research
(NINR). The event will focus on Economic Analysis of Nutrition
Interventions. The workshop will look at methods, research and policy issues. The NIH is soliciting comments. If interested in commenting or attending, contact Mike Bykowski at or 301-670-0270.
Comment: Integratorcolumnist Mike Levin
with Health Business Strategies has continuously brought the theme of
these potential savings to my attention over the past decade. One
sample: Columnist Levin: $24-Billion Savings through Supplement Interventions Says Lewin Group.
It is good to see the theme of cost savings via nutritional
interventions, long a part of the claims of integrative practitioners,
receiving this focused attention. Here is a hope that the methods
discussion will include using dietary supplements as part of a whole
practice intervention, as urged by the Council for Responsible Nutrition.
(Thanks to Douglas "Duffy" MacKay, ND, CRN's vice president for
scientific and regulatory affairs, for bringing this event to my
attention.)
March
Reform law requires non-discrimination
Insurance "non-discrimination" among 7
sections in the federal healthcare overhaul law that expand inclusion of
integrative practices
The Integrator Blog News & Reports recently published
a report that includes locations and
exact language of all of the chief sections of
the Patient
Protection and Affordable Healthcare Act (HR 3590), the healthcare
overhaul law. These sections, including 2706, non-discrimination,
will likely shape policy action relative to integrative practices in
coming
years. Complementary and
alternative medicine
practitioners and integrative practices are
included in sections 2706, 3502, 4001, 4206, 5101,
6301 and 2301. These relate, respectively, to: non-discrimination;
workforce planning;
community medical homes; wellness, prevention and health promotion;
individualized wellness plans; comparative effectiveness research; and birthing services. The
report includes the sections with the language related to integrative
practices in bold. Also included is a link
to a You Tube file which includes a useful analysis from a longtime
lobbyist for the chiropractic profession who called this combined
inclusion "major steps
toward recognition."
Comment: Fascinating that the concept
of "integrative practices" and "licensed integrative practitioners"did not exist in federal law until this law in 2010. It
is worth a moment of reflection on how far this movement has come, even
if slower than any of us might want. And, for those of you who
participate in US politics through contributing to elected officials, I include
photos of those elected officials who appear to have had the most
impact: Harkin, Mikulski, Sanders, Conrad and Cantwell for specific
sections; and Obama and ultimately Pelosi for shouldering the
legislation into law.
Note: This subsequent Integrator article reports the June 2010 of the American Medical Association to fight against the non-discrimination clause as part of this AMA's Scope of Practice Partnership to limit professional advancement of all other healthcare professions.
April
Pilot at Ford plant indicates
integrative acupuncture, mind/body, chiropractic reduces back pain
medication use and costs
A pilot study conducted with assembly workers
at the Ford Motor Company in Louisville, Kentucky utilizing acupuncture and
mind/body therapies in conjunction with conventional medicine provided the same outcomes as conventional back pain
therapies,
but reduced the use of pain medications among participants by 58%. The findings were published in a letter to the Journal of Occupational and
Environmental Medicine as An
Integrative Medicine Intervention in a Ford Motor Company Assembly Plant.In the study, one group received conventional pain management
therapies, including pain medications. The second group utilized
integrative
therapies, including acupuncture and relaxation/meditation CDs.Both of the groups received treatments over a six-week
period, with a 12-week follow-up. Kenneth
R.
Pelletier, PhD, MD(hc), a co-principal investigator on the study commented, in a release from HealthyRoads the provider of the CDs, as follows: "While the
sample size was insufficient to adequately estimate the effect of the integrative medicine
intervention on disability or absenteeism, the results have very
positive implications for employers looking to
manage their pharmacy costs associated with low back pain." Back pain is estimated to cost employers as much as $100 billion a year in direct medical expenses,
lost
workdays, reduced productivity, compensation payments and legal charges.
A release on the project is published here.
Comment: The leader at Ford, Walter
Talamonti, MD, offers an insightful look at the challenges one can face
in doing research in the onsite, employee-employer environment in this Integrator story.
Sebelius: Positions CAM as cost-effective
HHS Secretary Sebelius speaks positively on possible cost effectiveness from acupuncture,
homeopathy, alternative health care
In a question from a reporter following a talk at the National
Press
Club on April 6, 2010, US Health and Human Services Secretary Kathleen
Sebelius was asked about her "own view of using acupuncture,
meditation, and other alternative healing methods in health
care?" Sebelius response, printed
in
full
here, is generally positive, if apparently misinformed about the
limitations of the homeopathy category. In her comments, however,
Sebelius links these practices with patient choice, prevention,
potential cost-effectiveness and her comparative effectiveness research
initiative.
The following day, former chair of the Democratic National Committee
Howard Dean, MD, was stimulated to make a few remarks on
chiropractic and alternative practices, also reported
here. Dean relays an anecdote from his term as governor that is
unfavorable toward chiropractors, but then uses generally positive
language. Sebelius' remarks are
reminiscent of Obama's
own
comments
on acupuncture and other alternative approaches while
campaigning in 2008.
Comment: It must have been
interesting for Secretary Sebelius to catch these questions at the
National Press Club back-to-back with those she was asked by
Congressman
Tim Ryan (D-OH) during a Congressional hearing (below). The Secretary
may be served to request a short briefing paper so she can get her facts
right the next time a question is popped. Her general support, like
that
of Obama's, is good.
May
Lafferty: Lower costs from CAM users
Analysis of Washington insurer data finds CAM-using
insureds have lower expenditures than non-users
An analysis of insurance data in Washington state
found that "among insured patients with back pain,
fibromyalgia, and
menopause symptoms, after minimizing selection bias by matching patients
who use
CAM providers to those who do not, those who use CAM will have lower
insurance expenditures than those who
do not use CAM." Findings also indicated that:
"CAM users had higher outpatient expenditures that which
were offset by lower inpatient and imaging
expenditures. The largest difference was seen in the patients
with the heaviest disease burdens among whom CAM users averaged $1,420
less than nonusers, p<0.0001, which
more than offset slightly higher average expenditures of $158 among CAM
users with lower disease burdens."
Comment: Is there a hint here regarding
health reform priorities? The movement toward care from these covered
providers in both
studies is from inpatient to outpatient, from more costly procedures,
to
less invasive services, from machinery and edifice to time-intensive
treatment from licensed human beings. There is a parallel movement of
dollars, but with less overall cost. Credit
NCCAM for funding the work. (Thanks to Paolo Roberti Di Sarsina, MD for
alerting me to this study.)
Prefers discrimination
AMA Specialists Promote Repeal of Non-Discrimination
Toward Licensed
Integrative Practitioners, Others, in Section 2706 of Healthcare Reform
Bill
The ink was hardly dry on the landmark Non-Discrimination
in Health Care provision (Section 2706) of the Obama-Pelosi
healthcare overhaul, the Patient
Protection and
Healthcare Affordability Act, and MD specialists are pushing its
repeal.
Anesthesiologists and
ophthalmologists have asked the AMA to initiate a lobbying
campaign at the executive, Congressional and grassroots levels so the
Section 2706 of the 2010 law, scheduled to come into effect in 2014,
never does. The
request is framed as part of the AMA's ongoing Scope
of Practice Partnership against other professions. Section 2706 is
healthcare reform's most significant
inclusiveness measure for DCs, NDs, LAcs, massage therapists and
licensed midwives. Section 2706, if not repealed, could open consumer
choice to these practitioners to tens of millions of US residents. In
the name of patient protection, the two
AMA specialty societies are acting against their direct competitors,
nurse
anesthetists and optometrists, but taking out integrative practitioners
with them. A look at the language in the proposed resolution as it
will go to the AMA House of Delegates in June 2010 is available
here.
Comment: I
had the opportunity at the research conference of the Massage Therapy Foundation to be on a policy panel on May 13, 2010 with Deborah
Senn, the former Washington State insurance commissioner. Senn is
widely credited with saving a 1995 state statute that
was,
effectively, a "non-discrimination" law in Washington State
legislature. Senn repeatedly battled back the
courtroom and lobbying efforts of insurers for
repeal. She and I spoke of the likely battle ahead over Section 2706,
just 10
days before the campaign of the two AMA specialty societies,
noted above, came to light. Get involved, friends, if you want to see
this language stay in the law. Two coalitions that are likely to be
involved are the Integrated
Healthcare Policy Consortium and the Coalition for
Patients Rights. To gain a sense of the
potential battle ahead, the AMA's "grassroots" anesthesiologists average $311,600
to $446,994 of income per year and their "grassroots"
ophthalmologists average
$349,766. Redwood grasses, I guess.
"The Ornish Program for Reversing Heart Disease meets the intensive
cardiac rehabilitation (ICR) program requirements set forth by Congress
in §1861(eee)(4)(A) of the Social Security Act and in our regulations
at
42 C.F.R. §410.49(c) and, as such, should be added to the list of
approved ICR programs."
The decision memo requested final public
comment on the action, a 30 day period. Ornish mentions the action in
his Huffington
Post blog on May 15, 2010. Ornish writes: "This
is the first time that Medicare will be providing coverage for an
integrative medicine program, so we are grateful to everyone involved in
this decision."
Comment: Ornish has shown tremendous
perseverance on this work. Integrative
medicine leader Lee Lipsenthal, MD, who was involved for years with
the Ornish team, sent news of the action to the Integrator
with this comment: "This is the first time that a healthy lifestyle
program including
yoga and veggie diet will be covered as a treatment option from the
government." Here's hoping there are no glitches in the final comment
period.
American Botanical Council reports 5% growth in herbal
supplement sales in 2009 to over $5-billion
Sales of herbs in the U.S. grew by nearly 5% in 2009 to just over
$5-billion according to a May
7, 2010 report from the not-for-profit American
Botanical Council. Most growth was seen in sales via mainstream
retail outlets, such as drugstores. In these categories, sales soared
14th from 2008. ABC's
Mark
Blumenthal comments: "In
the most economically difficult market in over 70 years, when almost
all
consumer goods experienced a drop in sales, consumers voted strongly
with
scarcer dollars for herbal dietary supplements." The report found that:
5 top-selling via health and natural food
channel: aloe,
flaxseed oil, wheat grass and barley
grass, açaí, and turmeric.
5 top-selling
via food, drug, and mass market channel: cranberry, soy,
saw
palmetto, garlic,
and echinacea. (The rankings do not include herb combination
products.)
The HerbalGram report is based on herb supplement sales
statistics from market research firms Information Resources Inc. (IRI),
Nutrition
Business
Journal (NBJ), and SPINS.
August
Integrative naturopathic medicine shows significant savings
Model whole practice research shows
integrative naturopathic medicine effective and cost-saving for Canada Post employees
The preliminary results from a randomized controlled pragmatic trial of the whole practice
of naturopathic medicine for Canada Post employees
with elevated cardiovascular risk
found that treatment by integrative naturopathic doctors was both
effective and cost-saving. Naturopathic treatment produced an overall
$1025 cost benefit per participant. The Canada Post employees who were patients of naturopathic doctors showed significant reductions in levels of
cardiovascular risk and in the incidence of metabolic syndrome. The results were reported by Dugald
Seely, Bsc, ND, MSc and economist Patricia Herman, MS, ND, PhD, on
August 12, 2010 at the conference of the American Association of
Naturopathic Physicians. The researchers, who
are preparing to publish the results in a peer-reviewed journal, also
found benefits across numerous biometric and
self-reported health-related markers.
Comment: The methods for researching this whole
practice, individualized treatment are a model for all integrative
practitioners, whether integrative MDs/DOs, wellness-oriented DCs, AOM
practitioners or other multi-modal care-givers for whom reductive trials
fail to capture their practices. Happily, Strategic Objective #3 in the 2011-2015 NCCAM Strategic Plan (see above) suggests NCCAM will be moving more funding in this direction. The potential values of this approach are evident in a set of 8 commentaries
from various stakeholders on the Seely-Herman study. These indicate usefulness of these data to employer
purchasers, policy-makers, hospital administrators and clinicians
interested in practice betterment. In short, the Seely-Herman approach
is worth studying, emulating and amending as necessary. The study supplies critical
information for healthcare decision makers. For many in the naturopathic profession, the
outcomes are celebrated as a potential game-changer in their efforts to
expand inclusion of their services in the mainstream payment and delivery system.
8 Voices: Stakeholders on Seely-Herman Report of Canada Post Savings from Whole Practice Naturopathic Care for CVDReaders
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.More
Retreat program services covered
Pritikin Program covered by Medicare-Medicaid
On August 16, 2010 the Centers for Medicare and Medicaid (CMS) announced a
plan to cover the Pritikin Program for intensive cardiac
rehabilitation. A release from Pritikin notes that "the decision makes the Pritikin
Longevity Center & Spa, located in Miami, FLA, the first and only
residential healthy-lifestyle education program in the country to offer
Medicare-covered intensive cardiac rehabilitation." Pritkin's long road to coverage is described in this release:
"The criteria for coverage of an intensive cardiac rehabilitation
program by Medicare are stringent, including such requirements as
peer-reviewed, published research demonstrating that the program reduces
the need for bypass surgery as well as significantly lowers cholesterol
levels, triglycerides, body mass index, and blood pressure, and the
need for medications for cholesterol, blood pressure, and diabetes. Over
the past 35 years, more than 115 studies have been published in leading
peer-reviewed journals, including the Archives of Internal Medicine and the New England Journal of Medicine,
proving that participants in the Pritikin Program achieve these and
other significant health benefits, including substantial and sustained
weight loss.
Under the plan, Medicare will reimburse roughly $40 for
each 1 hour session of education
and for each 1 hour session of exercise at the Center. Coverage can be for up to six sessions per
day with a maximum of 72 reimbursable hours (roughly $2880 total) in the treatment plan. This fact sheet on the Pritikin site describes details of the coverage.
Comment: CMS' action on Pritikin
follows the recent announcement of coverage of the non-typical diet
and lifestyle program for seniors with cardiac risk led by Dean Ornish, MD. Whole person interventions to create health are finally gaining traction. (Thanks to Lucy Gonda for sending the link.)
Medicare to begin special chiropractic audit regarding maintenance care
A notice from the Chiropractic Essential Benefit Campaign
(CEBC) notes that Medicare "through its Comprehensive Error Rate
Testing (CERT) program, is scheduled
to begin a specialized audit of the chiropractic profession
nationally." The audit is to focus on the inappropriate use of the AT
(Active Treatment)
modifier on claims. Prior examination of the profession's billing
practices has found that a "significant percentage of chiropractic
claims inappropriately used this
modifier in an attempt to disguise maintenance or wellness care." The
CEBC, established to insure that chiropractic is in any national health
plan, argues that "this audit will be unfavorable to the chiropractic
profession and the results
will be used by insurers and major corporations like Wal-Mart as the
justification to keep neuromusculoskeletal conditions off the essential
benefits list." CEBC suggests that some
chiropractors justify this billing practice because chiropractic doctors
are the only healthcare professionals who are "required to perform
a service (exam) for which there is no reimbursement."
Comment: Pair this article with the recent AmericanChiropractic
Association-sponsored wellness certification course developed in
partnership with the National Wellness Institute (NWI). See article in
this Round-up. My guess is that practice by chiropractors of
"maintenance" chiropractic as "wellness care" will be altered if
delivered in the context of NWI's concept of wellness.
NCCAM DRAFT strategic plan includes health and real world focus - but no mention of cost in 5 "strategic objectives"
One August 30, 2010, NIH National Center for Complementary released its draft 2011-2015 Strategic Plan. This, the 3rd NCCAM strategic plan, is the first from the era of
Josephine Briggs, MD as director. The intriguing structure for the plan is built around 4 conclusions from the
team's landscape assessment, 3 overarching goals, 5 "guideposts for
keeping on track," 4 frames for priority-setting and and 5 strategic
objectives, all outlined in this article. The strategic objectives, as numbered in the plan, are:
Advance research on CAM pharmacological interventions.
Advance research on mind/body and manipulative/manual CAM interventions and practices.
Increase understanding of
“real-world” patterns and outcomes of CAM use and its integration into
health care and health promotion.
Improve the capacity of the field to carry out rigorous research.
Develop and disseminate objective, evidence-based information on CAM interventions.
September
Australian report finds cost benefits from acupuncture and natural product interventions
Cost effective if used as a complement
to standard care (medication, physiotherapy,
exercises, education), although not
generally cost effective when used as a
replacement to standard care (unless
co‐morbidity of depression is included).
St. John's Wort
Determined to be cost effective compared
to standard anti‐depressants forpatients with mild to moderate (not severe)
depression. The main driver is the lower
unit cost of St. John's wort.
Fish oils rich in
omega‐3 fatty acids
Highly cost
effective when used as an
adjunctive treatment in people with a history
of coronary heart disease, achieving reduced
death and morbidity. Not cost effective
in reducing non‐steroidal
anti‐inflammatory
drug use in rheumatoid arthritis.
Phytodolor
(proprietary herbal)
Cost
saving in managing osteoarthritis
compared with the principal non‐steroidal anti‐
inflammatory drug Diclofenac.
The National Center is hosted by the
University of Western Sydney. According to the report, "Australians spend over $3.5 billion each year on complementary medicines and
therapies,most commonly to assist in the management of chronic disease and improve health
and well-being."
Levin: Savings could be higher
Comment via Integrator adviser Michael Levin: The link to this study was provided me by adviser Michael Levin (thank
you Michael!). He subsequently pointed to this specific comment in the report: "The
exclusion of productivity costs
means that these results may be conservative. Chronic pain is
associated with
absenteeism from work and reduced
Double benefits from
acupuncture?
"If the presenteeism and
absenteeism costs of low-back
pain are averted, the benefits
from acupuncture would double."
work effectiveness (presenteeism). Access
Economics [the author of the report] estimated that in 2007 while the health system costs of
chronic pain accounted for 20% of the total costs, the burden of disease and
productivity losses associated with chronic pain each accounted for 43% of the
total cost. If the presenteeism and absenteeism costs of LBP are averted in a
one to one ratio with the burden of disease as Access Economics (2007) would
suggest, the benefits from acupuncture would double (or more than double if the
other indirect financial costs such as informal carer costs were also
included)."
Additional Comment: It is noteworthy
that the conclusion of the Australian government on St. John's Wort is
that the use of the herb is cost-effective while that of the U.S.
government, via NCCAM research on the herb, is that it is no more effective than a placebo.It is also noteworthy that including the concept of presenteeism in cost studies, see Levin's comment, as was done in this positive Canada Post-naturopathic doctors trial, remains very rare.
Survey data elevates questions on practice viability
NCCAOM survey finds stark challenges for most graduates of acupuncture and Oriental medicine schools
The
2008 Job Task Analysis by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) included a set of questions
on income, education debt and practice settings. The questions were added to fill gaps in the
profession's self-knowledge. A key finding: 70% of respondents gross
<$60,000 a year with significant percentages grossing less than
$40,000. Meantime, median student loan debt has grown to $56,000.
Publication of the findings has kicked off a
round of sometimes
acrimonious soul-searching in the profession. Lisa Rohleder, LAc, co-founder of the Community Acupuncture Network (CAN), captured the sentiment by reference to a well known children's book about a boy named Alexander and called the findings "the Terrible, Horrible, No Good, Very Bad Numbers." NCCAOM CEO Kory Ward-Cook, PhD, CAE, is quoted in this Integrator article on the subject, which includes a chart of key outcomes:
"I agree with [Rohleder's] analysis. It's sad
(that practitioners are making so little). This is the first time this
information is coming out. A lot of organizations aren't going to like
it. It's lower than they have been saying ...There appear to be schools where students thrive, and some where they don't .. We need to address the problem. Maybe
we don't need to graduate so many. Maybe we need to figure out how to
employ them. We've got to figure out if the profession will be a
two-tier system or non-tier, whether it will be doctoral level or
non-doctoral or both. We have to figure this out."
Rohleder, who has over the last 4 years engaged the
profession in a discussion about its economic viability and its ability
to reach patients, offers a pithy summation: "Acupuncture education, and the conventional acupuncture business model,
ought to come with a warning label, the way cigarettes do: NOT SUSTAINABLE. May take years of your life and leave you with nothing, except huge student loans."
Comment: I view these
data as a call to action. NCCAOM's findings that graduates felt
ill-prepared both on business issues and on collaborating with others is
a starting place. Addressing business issues needs to be a major
national campaign. Graduate them and they will come doesn't appear to be working.
Business model gains respect
Integrative medicine center True North teaches its distinct business model to Maine Dartmouth Family Medicine program
"A new paradigm of practice management in an integrative setting." This is the framing in a September 27, 2010 press release
from the True North Health Center regarding a talk the clinic's
executive director, Tom Dahlborg, gave to 3rd year residents at the Maine Dartmouth Family Medicine program.
The clinic has offered clinical rotations to residents in recent years.
This was the first venture into teaching the business side of
integrative care. The concepts may be new. At True North, "practitioners have the flexibility of choosing their own schedules and how much
time they spend with patients, and also contribute to organization-wide
decision-making, research studies, and collaborative case presentations." Dahlborg, who has 21 years of healthcare administration experience including 5 as True North's director, reportedly "emphasized the importance of not only working
alongside practitioners who have training in other modalities, but truly
collaborating with one another." The model Dahlborg shared includes "integrated charts, collaborative
development of patient care plans, participation in monthly circle case
presentations, and appropriate in-house referrals."Maine
Dartmouth Family Medicine Residency Program is one of eight Integrative Medicine in Residency (IMR) pilot sites associated with the
Arizona Center for Integrative Medicine.
Comment: I confess to being a fan of
mutual adoration societies, especially those that involve me. So having
tracked the True North work of medical director and founder Bethany
Hayes, MD, Dahlborg and others for a long while I was, as my father
would have put it, tickled to receive one of their releases, on October 4, 2010, that featured the Integrator coverage of True North over time.
Supplement sales up despite recession
Survey finds supplement sales strong despite, or because of, economic downturn
A survey by an independent polling firm contracted by the Council for
Responsible Nutrition (CRN) provoked a press release announcing that Retailers see strong supplement sales as consumer confidence holds steady.
66% of adults "label themselves as supplement users", up from 65% last
year and in the same ballpark since 2005. Those classifying themselves
as "regular users" also remained even. One supplement singled out as
seeing strong growth in sales is Vitamin D. The growth ids associated with emerging science. Others
"reported as steady and growing are probiotics, fish and flaxseed oil,
calcium and multiple vitamins." The article quotes a leader of a retailers' trade
association sharing that at a recent conference “everyone
was speaking of their uptick in supplement sales ...The economic effect
seems
to be pushing consumers towards supplements to maintain their health,
with the high cost of healthcare.”
October
Cost savings the focus of report
Bravewell publishes pamphlet on cost-effectiveness of integrative medicine
"A review of the medical, corporate and payer literature reveals that, to start, immediate and significant health benefits and cost savings could be realized throughout our health care system by utilizing three integrative strategies:
Integrative lifestyle change programs for those with chronic disease;
Integrative interventions for people experiencing depression; and
Integrative preventive strategies to support wellness in all."
Comment: This pamphlet is a conservative
presentation of the economic value of "integrative medicine." The
authors focus on the work of Dean Ornish in reversing atherosclerosis,
mind body stress reduction programs of Jon Kabat-Zinn with
depression, and corporate wellness programs. Not included are most of
the studies referenced by economist-researcher Patrica Herman, MS, ND,
PhD in her Systematic Review Yields Top 9 Therapies/21 Conditions with High Quality Evidence of Cost Savings from CAM.
Not mentioned anywhere in the Bravewell presentation are any outcomes
relative to practices by practitioners of massage, acupuncture,
chiropractic, yoga therapy, naturopathic medicine or dietary
supplements. (See, for instance: Analysis of Washington insurer data finds CAM-using
insureds have lower expenditures than non-users.) Still, this little booklet, downloadable here, should prove useful in some environments.
Half of therapists report business decline
Massage Today poll finds 2/3 of therapists seeing decline in clientele amidst economic sluggishness
An online poll from Massage Today
is finding that a steady 63%-65% of respondents responded "Yes" when
asked: "During this economic climate, have you experienced a reduction
in your number of clients?" Over a fifth (21%) report an increase and
the remaining 16% experience their business as more or less unchanged.
As of October 5, 2010, 563 individuals had responded to the online poll
that was published with the October 2010 edition of the online magazine
from MPA Media. A discussion among members of the massage field is
available at this Facebook page. The Massage Today poll ran with an article entitled: "Tough Times, Don't Panic: Use your downtime to build your business."
November
Insurer finds significant savings from chiropractic
Examination of Tennessee Blue Cross Blue Shield data finds
20%-40% lower costs for LBP patients who see chiropractors first
"For low back
pain, care initiated with a chiropractor (DC) is less costly than care
initiated through a Medical Doctor (MD). Paid costs for episodes of care
initiated with a DC are almost 40% less then episodes initiated with an
MD.
"Even after risk adjusting each patient's
costs we found that episodes of care initiated with a DC are 20% less
expensive than episodes initiated with an MD."
The analysis, carried out in 2006, was funded through a grant from the ACA. ACA president Rick McMichael, DC, shared with the Integrator
that "we think this is a very strong study, with major implications."
He attributes the outcomes to chiropractic medicine's "more conservative
approach" and how chiropractors "get in there and partner with
patients" to move them toward health. The study, says McMichael, "demonstrates the
value of chiropractic care at a critical time, when our nation is
attempting to reform its health care system and contain runaway costs."
McMichael shared that the project with the Tennessee Blues plan began
"some years
ago" through an ACA House of Delegates member who shared that he thought
the ACA might be able to access the insurer's data. Said McMichael: "We
always have feelers out to get access to data. We're happy
to put our approaches and services to the test." As another example, he points to the HMO
Illinois cost saving data via Alternative Medicine Integration Group, an Integrator sponsor.
Comment: At the time of my interview
with McMichael, the study had not yet produced or received much
mainstream media attention, other than this online Medical News link. I am reminded of comments by integrative cardiology researcher Eileen Stuart, RN, MS, PhD, regarding the reception of her scientific offerings at cardiology meetings. Stuart's research, published in top journals, had found significant benefits of a program she developed at Harvard with Herbert Benson, MDthat combined natural health measures for heart patients:
"I always have a few doctors come up after and ask about the program.
If these outcomes had been due to a drug, the doctors would have been flocking
around me."
Imagine what kind of media coverage we would see from a press release
like this: "New drug shown to save 20%-40% on treatment of conditions
that costs nation $50-billion annually." It doesn't help that ACA was
the study's backer, suggesting potential bias. Yet one wouldn't think
BCBS Tennessee would be interested in scamming the public on behalf of chiropractors. Better dead than red, I guess.Drug medicine uber alles.
Paper reviews strategies for economic evaluation in CAM The Use of Economic Evaluation in CAM: An Introductory Framework is a useful 24-page discussion article recently published in the open-access BMC Complementary and Alternative Medicine. The authors note that"in order for CAM to be extensively considered in health care
decision-making there is a need to expand the evidence-base for these
medicines and therapies and for the CAM research community to further
incorporate economic evaluation into research priorities (alongside
developing a broader health services research agenda)." They explore complexity issues, arguing that using a Markov model approach
could be useful. The authors conclude with this statement: "Whether
examining the use of CAM alone or as an integrated component of
contemporary health care provision, further consideration of economic
evaluation as a research tool is required. This paper provides an
impetus for those interested to pursue such a worthy goal."
Comment: The same journal recently published an analysis in South Korea of collaborative care for low back pain using acupuncture, using a "Markov model." The authors concluded that "acupuncture
collaborative therapy for patients with chronic LBP may be
cost-effective if the usual threshold is applied. Further empirical
studies are required to overcome the limitations of uncertainties and
improve the precision of the results."(Thanks to Mitchell Stargrove, ND, LAc for the heads-up on the evaluation paper.)
December
Comparative care plus comparative cost: Spine article offers additional data on relative effectiveness of chiropractic treatment
Within days of learning of the article noted above on comparative cost of chiropractic treatment, reader Wayne Bennett, DC sent notice of a favorable publication on comparative treatment outcomes. A team of 2 DCs and 2 Medtronic-affiliated MDs report in the December 2010 Spine that:
" ... compared to family physician-directed usual care, full clinical practice guideline-based treatment
including chiropractic spinal musculo-therapy treatment is associated with significantly greater improvement in
condition-specific functioning."
Top 10 People: Activist Chanda Hinton's Passion and Personal Experience Forge Integrative Pilot in Colorado-Medicaid
By most measures, over the past 5 years The Chanda Plan Foundation
has done extraordinary work to secure resources to help under-served
consumers who could benefit from integrative practices. The foundation
has raised and dispensed to patients over $400,000 from individuals and
foundations. Work in the legislature of the state of Colorado led to the
passage of House Bill 1047 (HB09-1047; 2009) that mandates the Integrative Medical Therapies (IMT) pilot program to study outcomes of integrative care in a disabled population covered through Medicaid. The project is a 3 year pilot program that will provide acupuncture, massage and
chiropractic to Medicaid recipients with long-term disabilities.The Foundation has also developed an adaptive yoga program
for veterans. These Chanda Plan Foundation programs have a common focus
on assisting people with disabilities to gain access to integrative
treatments. What is most remarkable, however, is that the power behind
the Chanda Plan Foundation, founder Chanda Hinton, is herself disabled after an accidental bullet from a 22 rifle hit her spine
between C-5 and C-6
at age 9. The infectiously positive Hinton states
matter-of-factly: "I'm a quad in a power chair with a service dog." I
would say, as I am sure the legislators she lobbied would agree, that
Hinton is power in a power chairand exceedingly charming at that. Most recently Hinton is expanding a relationship with the integrative medicine program at the University of Colorado
for research support. In November, Hinton contacted the NIH NCCAM to
explore potential funding. If it is "real world research" NCCAM wants,
the agency will find nothing more real than this.
__________________________
Overall Comments: What have I missed? Please let me know of any other key cost or economics-related reports or developments.
The year yielded a couple of eccentric, selective reviews (Bravewell, Austrialian). The challenges in gaining clarity are clear in the outcomes on chiropractic doctors. They smell like roses in the
BCBS Tennessee study (November) though are mixed at best in the huge Medicare pilot
(January).
Did any of you also enjoy the juxtaposition in the 2 May reports? One showed savings to insurers in Washington State and another reported the AMA's decision to campaign to undo the insurance "non-discrimination" in the federal reform act. Yet another example of choose your evidence based medicine, apparently.
The year's perseverance furthers award goes to the Dean Ornish team and to the Pritikin people for their now successful multi-decade campaigns for Medicare coverage. High-point for the year was the whole person integrative practice study with Canada Post employees (August). This is a model of what needs to be done with diverse practitioner groups and multiple chronic conditions.
The biggest question as the year draws to an end is whether costs will be elevated from its present invisibility in the draft NIH NCCAM 2011-2015 strategic plan's "strategic objectives" when the final is unveiled in February 2011. How else can NCCAM fulfill on the charge in Section C of the mandate to:
" ... study the integration
of alternative treatment, diagnostic and prevention systems,
modalities, and disciplines with the practice of conventional medicine
as a complement to such medicine and into health care delivery systems
in the United States."