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Institute for Health & Productivity Management - Integrative/Complementary Healthcare
Cost and Economics of Integrative Healthcare in 2010: 25 Brief Articles PDF Print E-mail
Written by John Weeks   
Wednesday, 29 December 2010

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.
Send your comments to
for inclusion in a future Integrator.

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?

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Prime mover in integration decisions
Yet while
getting-and-spending may 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

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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.

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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. 

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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

ImageNIH 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.
CommentIntegrator columnist 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

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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

ImagePilot 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.

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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

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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."
The results were part of a broad NIH NCCAM-funded initiative led by William Lafferty, MD, and published in the Journal of Alternative and Complementary Medicine as Comparison of health care expenditures among insured users and nonusers of complementary and alternative medicine in Washington State: a cost minimization analysis. Bonnie Lind, PhD was the lead author. This study follows a more limited study of fibromyalgia patients alone that reached a similar conclusion: "CAM use is not associated with higher overall expenditures. Until a cure for (fibromyalgia) is found, CAM providers may offer an economical alternative for FMS patients seeking symptomatic relief."
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.)

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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.

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Ornish: Program finally approved
CMS/Medicare takes huge step toward routinely covering Ornish's integrative cardiac program  


Following 16 years of lobbying and a major federal pilot project, the Centers for Medicare and Medicaid Services (CMS) is on the brink of routinely covering the revolutionary integrative medicine program developed by Dean Ornish, MD and the Preventive Medicine Research Institute to reverse coronary artery disease. One May 14, 2010, the agency published a Proposed Decision Memo which states that:
"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.

ImageAmerican 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

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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 CVD 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. More

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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 American Chiropractic 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:
  1. Advance research on CAM pharmacological interventions.
  2. Advance research on mind/body and manipulative/manual CAM interventions and practices.
  3. Increase understanding of “real-world” patterns and outcomes of CAM use and its integration into health care and health promotion.
  4. Improve the capacity of the field to carry out rigorous research.
  5. Develop and disseminate objective, evidence-based information on CAM interventions.

September

Australian report finds cost benefits from acupuncture and natural product interventions


The National Institute of Complementary Medicine (NICM), established with seed funding provided by the Australian Government and a New South Wales governmental agency has published a recent report that found cost effectiveness for most of the handful of therapies examined. The agency sent a September 13, 2010 press release entitled Economic report finds complementary medicine could ease health budget.

Modality/agent
  Finding
     
Acupuncture for chronic
low back pain
  
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 for
patients
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."
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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.

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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.

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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. 

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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


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Cost savings the focus of report
Bravewell publishes pamphlet on cost-effectiveness of integrative medicine


The Bravewell Collaborative of philanthropists for integrative medicine has published a new 16-page pamphlet entitled The Efficacy and Cost-Effectiveness of Integrative Medicine: A Review of the Medical Literature.  The authors are: Ermenia (Mimi) Guarneri, MD, Scripps Center for Integrative Medicine, Scripps Health; Bonnie J Horrigan, Bravewell's director of communications and public education; and Constance M Pechura, PhD, executive director of the Treatment Research Institute (TRI). The authors begin by indicating that
"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:
  1. Integrative lifestyle change programs for those with chronic disease;
  2. Integrative interventions for people experiencing depression; and
  3. 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.


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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

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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


"Starting with Chiropractic Saves 40% on Low Back Pain Care." So runs the headline in a November 16, 2010 release from the American Chiropractic Association (ACA). The study itself, by a team that includes well-known health services researchers Michael Finch, PhD and Christine Goertz, DC, PhD, carries a less effusive title: Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer.
The researchers found the following "practical applications" from the examination of records from 85,000 members of Blue Cross Blue Shield of Tennessee:

  • "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, MD that 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." 
See The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain.


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Hinton: Activist stirs Medicaid pilot
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 chair and 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."
Send your comments to
for inclusion in a future Integrator.


Last Updated ( Friday, 31 December 2010 )
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