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.

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

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

"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."

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

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

Comment:  Integrator 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.)

Reform law requires non-discrimination

Insurance "non-discrimination" among 7 sections in the federal healthcare overhaul law that expand inclusion of integrative practices

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.

Pilot at Ford plant indicates integrative acupuncture, mind/body, chiropractic reduces back pain medication use and costs

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 "

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.

Lafferty: Lower costs from CAM users

Analysis of Washington insurer data finds CAM-using insureds have lower expenditures than non-users

"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.

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."

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.)

Integrative naturopathic medicine shows significant savings

Model whole practice research shows integrative naturopathic medicine effective and cost-saving for Canada Post employees

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.

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.

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.)

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.

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.

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

"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." 

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,

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.

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."

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

"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.

• "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."
  

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.

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.)

" ... 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." 

Hinton: Activist stirs Medicaid pilot

Top 10 People: Activist Chanda Hinton's Passion and Personal Experience Forge Integrative Pilot in

" ... 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."