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Ira Zunin, MD and Manakai O Malama: Checking in on a Thriving Integrative Center PDF Print E-mail
Written by John Weeks   

Ira Zunin, MD and Manakai O Malama: Checking in on a Thriving Integrative Center

Summary: The 32 practitioner integrative clinic is nearing it's 250,000 patient visit. In the economically down year of 2009, volume and revenues expanded significantly. Findings of a significant, integrative, team approach to chronic pain, engaged through a contract with the state of Hawai'i's main insurer, HMSA, were published. The positive outcomes are holding over time. A significant consultancy with an integrative venture associated with an East Coast academic health center is coming to a close. Meantime, the founder and director, Ira Zunin, MD, MPH, MBA is in training with the Polynesian Voyaging Society to participate in a 2013 world tour. Here is an Integrator update on the Manakai O Malama clinic on the island of Oahu. 
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Ira Zunin, MD
The pleasure of an interview with Ira Zunin, MD, MBA, MPH is not only in
telephonically landing on the island of Oahu in Hawai'i and thus finding myself basking in remembered salt water, warmth and health associated with the place.

Nor is it entirely in learning of some activity with which Zunin is involved
that suggests that this early leader in integrative medicine clinical services, while nominally part of the same universe I inhabit, actually has at least one foot in another, more healthy universe altogether. More on that in a moment.

I also have Pavlovian anticipation on the professional front. My bias is
to see integrative practice established and flourishing via quality, replicable business models. Zunin will typically have some intriguing things to report in the area of integrative community medical services via his Manakai O Malama clinic.

The clinic's name translates loosely as the "healing spirit of the ocean." Those who have been around integrative healthcare's economic struggles will know that up-beat accounts, while more frequently heard in recent years, remain relatively few and far between.

My calls with Zunin,
an Integrator adviser, typically transmit one or more therapeutic idea for integrative care's economic doldrums. Given my biases in this line of work, these are pleasures to hear.

Pilot project with HMSA/Blue Cross of Hawai'i proving "durable and sustainable"

We started talking about a multi-practitioner research project he'd initiated. Zunin, who operates in part under his MBA training, struck up a deal for a pilot project for chronic pain patients through Hawai'i Medical Services Association (HMSA), a Blue Cross plan. HMSA is the dominant insurance carrier in the state. A preliminary 2008 Integrator report of the pilot indicated that the group-focused, mind-body approach was showing good outcomes.

Insurers partnered for the chornic pain pilot
Zunin shared that he is "delighted with the continued benefits to patients in call three areas" the pilot measured. These are quality of life, functional capacity, and effects on the use of healthcare resources. His team found continued benefits after a second intervention. In fact, the outcomes to date convinced Zunin that the multifaceted intervention "is durable and sustainable beyond the (time of the) intervention."

Research findings were published in the August 2009 issue of the Hawai'i Medical Journal and are available here online. The authors conclude, in the abstract:
"Post-treatment, patients demonstrated statistically significant decreases in somatization, depression, and anxiety, and statistically significant improvement in quality of life. Patient outcomes further showed substantial improvements with regards to functional capacity, as well as significant decreases in the utilization of healthcare resources. In conclusion, the preliminary evaluation of the CPP (Comprehensive Pain Program) suggests additional studies with a larger sample size and comparison groups are warranted to further evaluate critical components of the treatment regimen, clinical outcome, and cost-effectiveness."
Zunin is of the opinion that the group environment for delivery of the CPP was a significant factor in the positive results. Group-delivered services included both counseling/behavior change approaches and acupuncture.

Expanding the multi-disciplinary model 

Zunin is also excited with the pilot's "demonstration of the value of a multidisciplinary intervention." He shares that he is planning to research similar integrative approaches to other conditions. The Manakai O Malama team is presently exploring funding opportunities in two areas.

  • behavioral/mind-body approaches, including the use of movement, alone, for chronic pain, and
  • integrative strategies for metabolic syndrome (coronary artery disease and hyperlipedemia).

The latter is an important area of employer interest. Both would examine strategies that involve multidisciplinary teams.


Manakai O Malama: At a Glance

Note: Some data points are rough estimates offered
during an interview with Zunin.

Total providers
Visits per year

Visits by practitioner type

% Medical (MD/NP)
% Physical Therapy
% Massage
 % Acupuncture
 % Other (ND, DC,
Type of Conditions
 Primary care
 Neuromusculoskeletal   50%
Payer Type
Private payer (including a
small amt. of Medicare and
state's Quest program)
Worker's compensation




Provider mix: Honoring the clinic's nurse practitioners

Zunin makes it clear that part of the clinic's success is simply that "we've never had much competition." The only similar operations cast conventional portraits. One calls itself a rehabilitation clinic while the other focuses on occupational medicine. Manakai O Malama is the only significant outpatient center on Oahu which promotes its care as integrative healthcare services.

  "We've had a wonderful experience
with nurse practitioners in the past year.
They come from a culture of personal
responsibility and patient advocacy.
They don't seem to have the sense
of entitlement of physicians. They are
excellent team players."

A significant advance for the clinic in recent years has been the more expansive use of nurse practitioners. "We've had a wonderful experience with nurse practitioners in the past year," Zunin reflects. "I'm only now coming to realize that with the nurses we've had, the level of clinical acumen is astounding. These nurses come from a culture of personal responsibility and patient advocacy."

He adds that the nurse practitioners "don't seem to have the sense of entitlement of physicians." He has found those he has hired to be "excellent team players." With a diverse set of 32 practitioners, this is critical.

Zunin notes two other changes is the clinic's make-up of service providers. A physiatrist has been hired to support the clinic's neuromusculoskeletal focus. The clinic also has its first full-time naturopathic physician in Allison Bachlet, PhD, ND. New prescriptive authority for NDs in the state allow Bachlet an expanded practice model.

Toward the future: More primary prevention and the importance of the EMR

Zunin is happy with his practice and feels lucky to be in the field, doing the work he is doing, enjoying it more as he heads toward what he figures is his clinic's 250,000th visit. 

 Under health reform, more labor-intensive,
 integrative practices will have time to cost out.

"We'll get the ROI through prevention,
especially primary prevention," says Zunin.

Under his Global Advisory Services hat, Zunin is presently finishing up a series of strategic and business plans for a large university hospital group in the Southeast. He notes: “We continue to support organizations nationwide large and small to get it right."

Zunin believes that a significant, useful change coming through the recent healthcare overhaul is that insurers won't be able to drop customers as easily. Because of this, Zunin reasons, they will have more of a reason to think long-term and invest in preventive and health promoting approaches. More labor-intensive, integrative practices will have time to cost out. "We'll get the ROI [return on investment] through prevention," states Zunin, "especially primary prevention."

Zunin also calls on integrative practices to get with using electronic medical records (EMR). He sees these as tools through which methods for showing cost-savings from new care models can be quickly discovered and promulgated. "You can slice and dice anything at any time" with these systems, he says. Integrative medicine, he urges, "needs to become extremely competent in how it represents and records itself."

Polynesian Voyaging Society vessel
Coda: That other bit of full-life therapy from the Oahu based clinic

When I last connected with Zunin electronically while working on this article, he was freshly back from a week-long ocean sail. It wasn't on a glass-hulled vessel.

Rather, Zunin is in training to be part of world-wide voyage through the Polynesian Voyaging Society (PVS). Teams travel in vessels such as those in which South Seas peoples have traveled for centuries. The cruise, to begin in 2013, is the next in line of many since 1975 on the masted, reed-built vessels the PVS has sponsored. The cruise is in 32 segments, each of 2-4 weeks in duration.

Zunin feels that, with the addition of the physiatrist and Manakai O Malama's 3rd nurse practitioner, the clinic team will be able to operate without his hand on the tiller for the periods of time he is away.

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for inclusion in a future Integrator.

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