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Lorilee Schoenbeck, ND: Pioneering a Naturopathic PCMH in Vermont's Health Reform (Part 1) PDF Print E-mail
Written by John Weeks   

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.

Accredits ND-run clinic as PCMH
The news could surprise many. In the state of Vermont, as in Oregon, naturopathic physicians can, and do, operate accredited primary care medical homes (PCMHs).

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.

Pioneering ND-led PCMH
That designee was the Mountain View Natural Medicine center in Burlington. The pioneering force behind this opportunity in Vermont is naturopathic physician Lorilee Schoenbeck, ND. Her center is presently a Level 2 PCMH under a system of scoring carried out by analysts from the most significant accreditor of PCMHs nationwide, NCQA.

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.

    Table 1
Up-Regulation of Naturopathic Doctors
in Vermont

  Licensed in Vermont
2006   Included in private insurance
2007   Included as Medicaid practitioners
Expansion of prescription authority
2011   Included in PCMH language
2012   Recognized as primary care physicians
2012   Recognized as eligible to run PCMHs
2013   First naturopathic PCMH designated

Schoenbeck and the Emergence of NDs in Vermont

Schoenbeck: driving the PCMH recognition
Schoenbeck began laying the ground work for this level of participation by naturopathic doctors in the care of residents of Vermont 18 years ago when she arrived in Vermont to practice. She had recently completed medical school at National College of Natural Medicine after finishing pre-medicine at the University of Wisconsin. She previously completed a bachelors in nutrition from Vermont's Goddard College.
Table 1 delineates the step-wise advances of the naturopathic medical profession leading to inclusion in Vermont's primary care-focused blueprint.

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.

  Table 2
Practitioner Mix at
Mountain View Natural Medicine

  Naturopathic physicians
  1 MS Dietician

Plus, under the
Community Health Team:
Part-time social worker
  Part-time acupuncturist
  Part-time health coach
  Part-time nutritionist

Mountain View Natural Medicine's team
Payments to Vermont PCMHs are linked to the size of the population that uses the clinic, and to the level at which the PCMH is accredited. The level of accreditation is tied to the score the clinic obtains as audited by the NCQA. NCQA provides these scores to Vermont's Blueprint for Health. The Vermont staff then independently recognizes qualifying naturopathic clinics as either Level 1, 2 or 3 PCMHs.

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
Remarkably, Mountain View is provided an "annual budget for the Community Health Team" (CHT). For Schoenbeck's clinic, this amount -
tied to patient numbers - is currently around $30,000. The CHT payment can be used to pay for "ancillary providers who augment other clinical services in providing comprehensive care."

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]

Partner on the PIHTA project
: One of the truisms in creating full respect between health professions is that each needs to understand something of the history and, as the Fetzer Institute's Relationship Centered Care report put it, the "power relationships" of the other. For understanding the naturopathic medical profession, a meditation on the energy fueling the step-wise path that Schoenbeck and the Vermont Association of Naturopathic Physicians took in making these advances is a good starting place. Such a meditation is especially valuable for those
such as MDs and nurses who have come to integration with substantial formal cultural authority, are licensed in all states, covered by insurance, and etc.,

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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