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background resources in PDF |
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some CAM/IM publication links |
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Lorilee Schoenbeck, ND: Pioneering a Naturopathic PCMH in Vermont's Health Reform (Part 1) |
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Written by John Weeks
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Lorilee Schoenbeck, ND: Pioneering a Naturopathic PCMH
in Vermont's Health Reform (Part 1)
This
article is produced as part of a recent partnership between the Project for Integrative Health and the Triple Aim
(PIHTA) and the North American Board
of Naturopathic Examiners (NABNE). The Integrator is providing media
support. The goal of the partnership is to stimulate understanding
of naturopathic integrative patient centered medical homes (PCMH) via portraits
of clinics in Vermont and Oregon. PIHTA is an initiative of the Academic Consortium
for Complementary and Alternative Health Care (ACCAHC).
This is the first
of two parts.
The second part will focus on prevention and clinical improvement initiatives.
The series is related to the PIHTA-Casey Health Institute partnership on an integrative MD-led PCMH accessible here.
.jpg "Image") Accredits ND-run clinic as PCMH
In Vermont, naturopathic physicians do so following a
steady stream of up-regulation over the past 20 years. Licensing. Recognition as
part of the state's primary care matrix. Insurance coverage. Medicaid inclusion.
Most recently, in 2011, inclusion as accepted owners and operators of PCMHs
under the state's single-payer style Vermont
Blue Print for Health. Then in 2013, the first PCMH designation.
.jpg "Image") Pioneering ND-led PCMH
This interview with Schoenbeck was engaged to assist any
stakeholders interested
in better understanding this emerging role for naturopathic and other integrative physicians in
health system transformation. These could be regulators, payers, major medical delivery
organization administrators, and other naturopathic doctors. This work is a companion initiative to that exploring an
integrative
MD-led PCMH.
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Table 1
Up-Regulation of Naturopathic
Doctors
in Vermont
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1996
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Licensed in Vermont |
| 2006 |
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Included in private insurance |
| 2007 |
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Included as Medicaid practitioners |
| 2009 |
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Expansion of prescription authority
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| 2011 |
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Included in PCMH language |
| 2012 |
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Recognized as primary care physicians |
| 2012 |
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Recognized as eligible to run PCMHs |
| 2013 |
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First naturopathic PCMH designated
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Schoenbeck and the
Emergence of NDs in Vermont
.jpg "Image") Schoenbeck: driving the PCMH recognition
As an integratively-oriented clinical leader, Schoenbeck
practiced independently for 10 years in a Planned Parenthood owned gynecology
clinic. She was the first naturopathic physician to offer natural medicine in that
setting. Schoenbeck subsequently formed and grew the now 5 naturopathic physician,
plus, Mountain View Natural Medicine.
For most of her nearly two decades in Vermont, Schoenbeck
has also served as a political leader of her profession's state association,
the Vermont Association of
Naturopathic Physicians. She has also held top-level positions with the
American Association of Naturopathic Physicians (AANP) as board member, and chair of the AANP's State and Federal Affairs Committee and State
Alliance. Her work has primarily involved
providing training and tools for naturopathic doctors throughout the country who are involved in
licensing, scope modernization, and insurance legislative initiatives. She's also helped to drive the federal efforts for ND recognition in Medicare and the
VA
Multiple Levels
and Types of Payment
The base level of payment at Mountain View is straight
fee for service (FFS). The 5 naturopathic physicians bill as any primary care
doctor would in the FFS environment. The MS Dietitian can also bill as FFS directly under Medicaid and under many private
insurance programs as a covered provider.
As a PCMH, Schoenbeck's clinic has attendant care
coordination responsibilities for its patient population. These are expected
to drive down overall costs through such means as reduced use of
the emergency room and reducing unnecessary duplication of tests and services. In agreeing to
engage these services, Mountain View receives bonus payments.
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Table 2
Practitioner Mix
at
Mountain View Natural Medicine
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5
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Naturopathic physicians |
1
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1 MS Dietician |
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Plus, under the
Community
Health Team: |
1
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Part-time social worker |
1
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Part-time acupuncturist |
1
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Part-time health coach |
1
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Part-time nutritionist |
____________________________
.jpg "Image") Mountain View Natural Medicine's team
Mountain View Natural Medicine serves roughly 3,000
patients. Of these, 60% of the patient population has officially declared the center as their primary care provider.
Many of the other 40%, while technically designated as "specialist"
patients, see the NDs at Mountain View rather than their declared PCP for most
health concerns. Payments are based on
actuarial data from the insurers regarding where the patient receives
the majority of his/her care.
In Vermont, the state gives "enhanced payments" of
between $1 and $2 "per member per month" (PMPM) for, as Schoenbeck clarifies,
"patients who primarily see us over a 24 month period." The differential
between $1 PMPM and $2 PMPM is determined by the center's accreditation level.
As a Level 2 PCMH, Mountain View Natural Medicine receives $1.5 PMPM.
Special Payment
for the "Community Health Team"
Schoenbeck adds that the PMPM is "only one of the
financial incentives" her clinic earned through its participation as a PCMH. These payment, again, respect for the investment needed to re-tool the clinic as a PCMH. They are also linked to the additional patient care responsibilities the center has plus requirements for reporting, outcomes measurement and quality improvement.
 CHI's partner on the project
Basically, the payers of this fund, who are the actual insurers, believe
that the investment in the CHT will be more than recouped through better health
and through diminished use of high cost services.
Schoenbeck expresses excitement that, with regard to the CHT:
"Obamacare provides a lot of flexibility on who you populate that team with."
She ticks off the potential that the clinic can bring to her patients. The
services not covered under FFS of registered dietitians, social workers, and
nurse case managers are typical examples.
However, adds Schoenbeck, "our clinic has been a little
more creative." They've used the CHT fund to provide the care of an acupuncturist, a health
coach, a social worker and panel manager nutritionist. None are listed
providers under Vermont's Medicaid plan. These practitioners are then paid by Mountain View through their CHT funds.
From the patient's perspective, says Schoenbeck, this is
"additional care at no costs." And from Schoenbeck's view: "It's still amazing for
low income patients to have free access to social work, acupuncture to
coaching." She notes that whatever they can bill through insurance they do,
rather than using the CHT fund.
[Part II: Quality Improvement Initiatives at Mountain View
Natural Medicine]
_________________________________________
.jpg "Image") Partner on the PIHTA project
Each of the hard-won gains in the chronology prepared the landscape in which the option for patients of a naturopathic, integrative, patient centered medical home could grow. Schoenbeck and her colleagues achieved each in partnership with patients and through relationships built with elected officials. They paid in sweat mission (no equity, thus no "sweat equity" per se) with very little or zero philanthropic investment or governmental support. Likely they faced antagonism. For that reason, this accomplishment of this opportunity for integrative patient care is all the more remarkable. Part 2 of this interview with Schoenbeck will focus in on the prevention and clinical quality improvement initiatives the clinic has engaged.
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