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 Volume II

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 Tuesday, December 5, 2000

 8:00 a.m.

 (Morning Session)

 Hubert H. Humphrey Building, Room 800
 200 Independence Avenue, SW
 Washington, D.C.



James S. Gordon, M.D., Director
The Center for Mind-Body Medicine

Commission Members:

George M. Bernier, Jr., M.D.
Vice President for Education
University of Texas Medical Branch

David Bresler, Ph.D., LAc, OME
Founder and Executive Director
The Bresler Center, Inc.

Thomas Chappell
Co-Founder and President
Tom's of Maine, Inc.

Effie Poy Yew Chow, Ph.D., R.N., DiplAc (NCCA)
Qigong Grandmaster
President, East-West Academy of Healing Arts

George T. DeVries, III
Chairman, CEO of American Specialty Health

William R. Fair, M.D.
Attending Surgeon, Urology (Emeritus)
Memorial Sloan-Kettering Cancer Center
Chairman, Clinical Advisory Board of Health, LLC

Joseph J. Fins, M.D., F.A.C.P.
Associate Professor of Medicine
Weill Medical College of Cornell University
Director of Medical Ethics
New York Presbyterian Hospital-Cornell Campus

Veronica Gutierrez, D.C.
Gutierrez Family Chiropractic

PARTICIPANTS (continued):

Wayne B. Jonas, M.D.
Department of Family Medicine
Uniformed Services University of the Health Sciences

Charlotte Kerr, R.S.M.
Traditional Acupuncture Institute, Inc.

Linnea Signe Larson, LCSW, LMFT
Associate Director
West Suburban Health Care
Center for Integrative Medicine

Tieraona Low Dog, M.D., A.H.G.
(Private Practice)

Conchita M. Paz, M.D.
(Private Practice)

Buford L. Rolin
Poarch Band of Creek Indians

Julia R. Scott
National Black Women's Health Project

Xiao Ming Tian, M.D., LAc
Director, Wildwood Acupuncture Center
Director, Academy of Acupuncture &
Chinese Medicine
Wildwood Medical Center

Donald W. Warren, D.D.S.
Diplomate of the American Board of
Head, Neck & Facial Pain

Commission Members Not Present:

Dean Ornish, M.D.
Preventative Medicine Research Institute
Clinical Professor of Medicine
University of California, San Francisco

PARTICIPANTS (continued):

Executive Staff:

Stephen C. Groft, Pharm.D.
Executive Director

Michele M. Chang, C.M.F., M.P.H.
Executive Secretary

Doris A. Kingsbury
Program Assistant

Geraldine B. Pollen, M.A.
Senior Program Analyst

Joseph M. Kaczmarczyk, D.O., M.P.H.
Senior Medical Advisor

 C O N T E N T S

 Page No.

Session V: Meeting Public Needs/Systems of Delivery

  Private Practice
  Robert Atkins, MD ................................. 6

  Charlotte Eliopoulos, RCN, MPH, PhD .............. 12

  Stand-Alone CAM Center
  Mort Rosenthal, MBA .............................. 16

Panel Discussion ................................... 22

  Community Health Clinics
  Tom Trompeter, MPA ............................... 54

  Hospital-Based Centers
  Sylver Quevedo, MD ............................... 60

  Academic Centers
  Woodson Merrell, MD .............................. 65

Panel Discussion ................................... 70

  Managed Care Organizations
  James Dillard, MD, DC, CAc ...................... 105

  Anna Silberman, MPH ............................. 110

  Lori Bielinksi, LMP ............................. 115

Panel Discussion .................................. 121

  Robert Schneider, MD ............................ 143

  Naturopathic Medicine
  Tori Hudson, ND ................................. 149

  Traditional Chinese Medicine
  Robert Duggan, MA, MAc .......................... 155

Panel Discussion .................................. 160

Public Comment
  Bruce Nordstrom, American Chiropractic
    Association ................................... 195
  Neal D. Barnard, Physicians Committee
    for Responsible Medicine ...................... 198
  Doreen Chen, Chinese Medicine Council, AAOM ..... 201
  Gary Sandman, Integrative Medicine, LLC ......... 204
  Danny Freund, Pennsylvania State University ..... 207

Panel Discussion .................................. 210

  Melinna Giannini, Alternative Link .............. 224
  Jane Hersey, Feingold Association ............... 226
  Boyd Landry, The Coalition for Natural Health ... 229
  Lawrence A. Plumlee, National Coalition for
    the Chemically Injured ........................ 232
  Michael J. Rohrbacher, Certification Board for
    Music Therapists, Inc. ........................ 235

Panel Discussion .................................. 239

  Andrew L. Rubman, American Association of
    Naturopathic Physicians ....................... 249
  Marshall H. Sager, American Academy of Medical
    Acupuncture ................................... 252
  Diana Miller .................................... 255
  Courtney Banks .................................. 257
  Richard Pavek, Biofield Research Institute ...... 260

Panel Discussion .................................. 263

Session VI: CAM Integration in Existing Delivery Systems

  Alan Trachtenberg, MD, MPH
    Substance Abuse and Mental Health Administration
    (SAMHSA) ...................................... 273

  Milton Hammerly, MD
    Catholic Health Initiatives ................... 278

Panel Discussion .................................. 282

Session VII: Commissioners' Discussion ............ 304

Adjournment ....................................... 349

 P R O C E E D I N G S [8:00 a.m.]

 [Moment of silence observed.]

 Session V: Meeting Public Needs/Systems of Delivery


MS. CHANG: Good morning, everyone. We are going to get started, so if the first panelists could please come to the table. The first panelists are

DR. Robert Atkins and

DR. Charlotte Eliopoulos, and Mort Rosenthal.

DR. GORDON: Thank you very much. I want to thank all of you for a long day, a long attentive day yesterday, and for being here bright and early this morning, ready to roll. And thank you, too, for coming early this morning, those of you on the panel. So we will move down. The panel will begin with

DR. Robert Atkins. Good morning, Bob. Session V: Meeting Public Needs/Systems of Delivery

DR. ATKINS: Good morning. We are going to speak from the vantage point of a doctor who practiced a different kind of medicine, just with the idea of getting better outcomes, and this began in 1972 when he got a little disillusioned with statements made by the American Medical Association, when they basically said that the work that I had already observed with the regard to the effect of changing one's diet was not supported by the scientific literature. I would have to tell you that the idea for my diet came from The AMA Journals, and it was the teaching at the time, 1963. So I vowed that the best thing that I could do would be to just try to practice medicine more effectively than mainstream medicine was doing. After about 15 years of that, I came to the conclusion that we had succeeded in many areas in getting better outcomes certainly than I had gotten when I was practicing mainstream internal medicine and cardiology. So I wrote a book and the purpose was to describe the new medicine. I hit upon the title of "Complementary Medicine," and the book was called "

DR. Atkins' Health Revolution: How Complementary Medicine Can Extend Your Life." The reason I say this is because I do believe that the term complementary medicine very much applies to a practicing physician and is, in fact, what I think should be the future of mainstream medication, because if we define complementary medicine as I have defined it, and the way my colleagues and the groups that I belong to, the Foundation for the Advancement of Innovative Medicine, AKM, and so on, it is not that we are adding complementary therapies to mainstream medicine, but rather it is an entire system of patient care, a different system, a system which is based on a working knowledge of all of the healing arts. I say "working knowledge" because I think when we make our decisions, we select therapies from all of the healing arts based primarily on the highest benefit-to-risk ratios and on their ability to synergize with other therapies. Now it turns out that when we use the benefit-to- risk ratio, you end up using an awful lot of nontoxic nutritional therapies and a lot less of the pharmaceuticals, mainly because of the risk involved with pharmaceuticals. It incorporates mainstream thinking, though it incorporates mainstream thinking when it applies, but not when it excludes, safe and alternative therapies. It recognizes the multifaceted aspects of illness and expects all aspects to be considered in patient care. The term holistic really applies here. It feels that in enhancing the host's resistance to illness is often more important than destroying the illness itself. The most striking example of that is in cancer therapy, where host resistance or host strengthening is not a part of mainstream teaching. Its therapies, which are very often nutritional, work synergistically, and optimal results will not be achieved with single therapies. I say all of this became complementary medicine's effectiveness needs to be proven, and for many reasons, it is the lack of proof and the need for proof which is at the top of the list of things that would have to be done. In order to convince the other practitioners of mainstream medicine that they should expand their horizons to include alternatives, to include safe, nontoxic alternatives, and consider them perhaps as better alternatives than pharmaceuticals and surgery. The first order of business is to have it proven that it works, and that it gets better outcomes, at least equivalent outcomes, or that it helps cut down the cost of medical care, which is another important point, but in some way, something has to be proven. Now, complementary medicine offers the government an opportunity to solve its most pressing health problem, and how best to solve the problem of increasing health care costs. The American Ministry of Medicine has been allowed to develop protocols involving optional surgery, described as mandatory. People are not told that their heart blockages are reversible, is a perfect example, or expense, risky therapies that are given unnecessarily, such as giving adjutant cancer therapy to people when the surgeon has already removed the cancer, and also the use of drugs with side effects when vita-nutrients can do the same job. The result is the U.S. has the greatest per capita health care expenses in the world. Complementary medicine, by providing inexpensive, nutritional and non-surgical options, can go a long way towards cutting these expenses, and if the results that I have gotten, and my associates and the organizations that I belong to hold up to scrutiny, the number of hospital stays will plummet dramatically and, therefore, I think we can do some research that I think will point in these directions. Thank you.

DR. GORDON: Thank you very much, Bob. One of the things, before we move on to

DR. Eliopoulos, that I want to say to remind the Commissioners of, and also inform all of you about, is that these panels, these first couple of panels today, are opportunities for us to see how people are doing integrative, alternative, complementary, holistic practice in the community in various different kinds of settings. In fact, that is going to be the focus of much of the day. I am hoping that what we will do with each panel, is, after they give their brief statement, we have a lot of time for discussion, or a significant amount of time for discussion, and it will be asking them the questions about service delivery that will focus on ways of delivering services: what is effective; what is not; what is cost- effective; how is it working in their community; how is it working in their particular setting. We will have plenty of time in subsequent sessions to come back to issues of licensure, education, and research, but these are the folks we brought in specifically because of their expertise in service delivery. So I want to remind us all of that so we can focus on and get the most out of the sessions. Okay, next will

DR. Charlotte Eliopoulos.

DR. ELIOPOULOS: I am here representing the American Holistic Nurses Association, an organization of RNs that is committed to mind, body, spirit healing. The nursing profession has a long history, and perhaps the longest of any health care profession, at providing care in a holistic manner. We believe that a holistic approach to care is essential to the healing process. We are enthusiastic supporters of the integration of CAM as part of a holistic comprehensive plan of care. Providing a CAM product or therapy without assessing and addressing the total needs of the person really risks perpetuating a system of fragmented care and really dilutes the beneficial outcomes that are potentially available. To nurses, it is not a matter of CAM or conventional care, but really using the best of both worlds to achieve optimal results for clients. We believe that nurses must have a significant role in this integration of CAM into the health care system at large, and there are several reasons for this. First of all, being that nurses represent the largest group of health care professionals, over 2 million of us out there, in a wide range of clinical settings as diverse HMOs, emergency departments, hospice programs, home health, and on and on and on. Our education prepares us to coordinate care, and responsibilities that nurses have assumed for probably as long as our existence has been one of coordinating, and it seems reasonable to think that we could also coordinate the integration of CAM with conventional practice. Nurses are uniquely educated, I believe, in first of all recognizing abnormality from normality in their assessment process, to be able to identify needs that fall within the realm of biological, spiritual, socio-economic and so on, and finding the right resources to meet them. Coordinating the efforts of a multi-disciplinary team, I think, has been a unique nursing function, and using a wide range of services to provide care, and also to evaluate outcomes. Nursing standards really emphasize advocacy of the client, so protecting them in their use of CAM, in their integration of that into the health care system, seems reasonable. Nurses also recognize the cultural and the psychological and the spiritual needs that affect health care choices and practices. Nurses are ethically, professionally and legally responsible for protecting clients and advocating for their well being, and also nurses enjoy a high degree of consumer confidence. We believe there are a number of actions that nurses can take to facilitate the access and delivery of CAM products and practices, first of all, being to increase our own knowledge base through continuing education for the existing work force, as well as the integration of this within the undergraduate nursing programs, also to stimulate the development of systems to help with the access and delivery of these services. I am speaking of things such as assuring policies and procedures are in place within the existing health care system to assure that services are being safely utilized, and so on. Advocating and demonstrating a holistic approach to the delivery of these services is also important, and also for nurses to derive private practices where they can utilize some of these therapies themselves, which many of them already are. They are doing it in terms of helping people with developing healthy lifestyle practices, managing chronic conditions in a natural manner, and coordinating the services of both conventional and CAM practitioners. The AHNA supports an integrative approach to the delivery of CAM products and services, and we recommend that reimbursement and policy decisions be made to facilitate that, and that part of those decisions need to consider some reimbursement for nurses to facilitate the assessment, the coordination, the monitoring of the utilization of these services. Also, that nurses be looked at as well prepared, cost-effective coordinators and monitors in, using a catch term, gatekeepers of these services. They have got a history of demonstrating they can do this with conventional care and it certainly would make sense to utilize that expertise. We thank you for this opportunity to present a voice for nursing on this commission. Thank you.

DR. GORDON: Thank you. Mort Rosenthal is next. We have a couple of corrections here. The testimony should be behind Section V, Tab C, and we need to replace page 8 and 10 of

MR. Rosenthal's testimony. I think Joe gave you those sheets.

MR. ROSENTHAL: I don't know what is on page 8 and 10, but I deny it. I am the chairman and founder of Well Space. Well Space is attempting to consolidate and brand the CAM market, making it safer and more accessible. We believe we are creating a consumer benefit, a practitioner benefit, and we believe that there is a business opportunity created by that consolidation. Brand will mean safety and quality in the consumers' mind, which will help create access. We opened a prototype center in Cambridge 27 months ago. We have 21 treatment roo

MS. Since then we have seen 10,000 patients, excluding our classes. We have had about 40,000 visits. To give you a sense, we are open 90 hours a week, seven days a week. We employ 70 practitioners. This year we will do about $2 million and we will make some money on that, not enough, but some money. Not enough to justify their role. We offer many modalities of massage, acupuncture, Chinese herbs, chiropractic, naturopathic medicine and nutritional classes. We see about 100 new patients a week. We get 60 percent of those from referral, from ear-to-mouth referral. Twenty percent drive by, or walk by, and about 10 percent from medical referral. We treat a whole range of conditions. About 45 percent of our visits are related to stress, or relaxation, and the rest are specific medical conditions like pain, headaches, back and neck pain, sleep disorders, fibromyalgia, fatigue, everything to cancer. We are complementary, not integrated. We are attempting to create an idealized delivery system for health care, and have concluded that that necessitates a system that is neither modeled after nor dependent on the existing health care system. When you do something in CAM, there are not barriers and legacies that you would have to deal with in more conventional care. To be successful, and I think we are pretty successful, it requires a real business focus. I think to be sustainable, whether you are for-profit or not-for- profit, you require that business focus which is on operational excellence, quality service, and cost control. A lot of that is driven by the fundamental economics of the CAM industry. A successful CAM practitioner, with the exception of certain acupuncturists and chiropractors, probably will make between $30,000 and $60,000 a year. The margins that we get in our business are about 33 percent, which means that we charge 1-1/2 times what the practitioner takes home. If you look at traditional health care, conventional health care, the multiples are between three and seven times. That means there is a whole lot more margin to play with in the delivery system. If you look at any service business, the multiples are typically three to seven times for accountants, lawyers, et cetera. So the margins are tight, and that means we have to focus on expenses that are focused on quality service and affordability. We have a heavy investment in systems and processes that allow us to deliver consistent quality from visit to visit. Another key aspect is simply the attention to our customer, to the patient. Patients are making a choice to come to Well Space. They needed to be treated like a customer, with the single overriding principle being that every touch is an opportunity to deliver care and create loyalty. For example, patients never, never, never wait for an appointment. The money transactions are done easily and simply. Appointments are available when a patient wants them. If education is needed, it is done in a nonthreatening, informative and sensitive environment, and the physical environment supports the mission in terms of appearance and all of the other senses that are fed by walking in by walking in the door at Well Space. The other key part of what we do well is attention to the practitioner. In CAM, perhaps more than other forms of health care, the practitioner-patient relationship is really critical, the best practitioners definitely have the best outcomes. So we need to attract the best practitioners in order to be successful, and we need to focus on them from an economic perspective, from a policy perspective, and from a cultural perspective. So our practitioners are attracted to a community which is both within their modality as well as the cross- multiple modalities, so they can practice with other professionals. It is a very professional working environment, and notes are filled out on every visit, for example. Their practices are managed so that all they have to do is deliver the care. They don't have to worry about anything else. Their compensation is probably better, but it is certainly more reliable than it would be in private practice, and they get benefits that are otherwise not available. We have a heavy investment in systems, as I mentioned. There are three key systems: resource planning, which drives utilization; appointments and point of sale; and finally, medical records. Whereas, I said we developed a system that allows for a point-and-click creation of a sub note based on our modalities. Briefly, I want to talk about our relationships to physicians. We have excellent relationships with local physicians. We do get, I would say, referral, but I put that in quotes. It is more you should try Well Space, or you should try acupuncture, as opposed to a traditional referral. Importantly, our patients are simply not interested in integrative care. We have the capability to create progress notes. Literally nobody has asked for information to go back to their physician in 40,000 visits. Finally, a bit about managed care. We did a pilot study with 2000 lives that were given essentially free access to CAM without medical referral, without any pre- existing condition. In a six-month period, about 70 people took advantage of that. Of the 70 people, when we completed the pilot, of the 70, about 50 continued to come and pay out of pocket. I think what that says is that there is not a lot of price sensitivity in this market. If you are in pain, the cost of the pain far exceeds the cost of the acupuncture treatments to address the pain or something like it. From a policy perspective, very briefly, I think the delivery system for CAM will continue to be largely stand-alone. Of the $20-odd billion, I would say 99 percent of it is delivered by individual entrepreneurs who are practitioners, whose success is a function of their outcomes, because otherwise their clients will not come back. I think any policy needs to not necessarily have a bias in favor of integration, because otherwise I don't think it will work. Panel Discussion

DR. GORDON: Thank you very much, all three. I am sure there are a lot of issues that we would like to discuss with you. Who would like to begin? Let me start then. Bob Atkins, I want to ask you what your sense is, both of the economics of your practice, the economics and sort of economic and social aspects of your practice? And also given the fact that you are an extraordinarily well- known author, what are the implications for other people who are not so well known, although they may be reasonably well known in their communities?

DR. ATKINS: Well, it is a tough question because being well-known has really changed the demographics of our patient population. Some 40 percent of the people now come from so far away that their follow-up has to be done through telephone counsels very often, and only an occasional visit. But most of my career, practicing that way wasn't like that. Basically we started off just being part of the system. In other words, when they had insurance, we applied for insurance, and they got reimbursed that way. Every once in a while there would be proble

MS. There are certain areas of care that we are very happy with that are being suppressed, and one of them, the first one that comes to mind is the high resolution microscopy that is very much a part of our diagnostic system. With this microscope, which was an expensive investment, we can see the material between the red blood cells. We can make diagnoses of various bacteria, yeast parasites, because we actually see them in their characteristic way of clustering under the microscope. Now we were told by CLIO that we can't do that, that we have to basically close that down. This is going to be a very painful part because so much of our understanding of patient care was based on that. Then various states, of course, have --

DR. GORDON: Do you want to explain what CLIO is and what that means?

DR. ATKINS: Well, that is a laboratory surveillance, so to speak, group. And they said yes, we love your lab, you get 100 percent success, but high resolution microscopy doesn't have any codes for it, so you can't use it. So that is typical of many of the obstacles. In treating cancer patients, of course, it is a disaster because the treatments that we read about or that I learn about when I go to international conferences, and I see that they are the most successful treatments that are alternative to chemotherapy and radiation, such as hyperthermia, which I am very pleased with. But there are no legal hyperthermia devices that will provide whole-body hyperthermia legal in the United States so we have to go to Europe or Mexico, and send our people there. There are an awful lot of other therapies that have not been approved. Treating multiple sclerosis, we found a very effective treatment, AEP, calcium AEP injections. Legal in Europe, but not in the United States, and they are not even allowed to bring into the country, and yet it is a perfectly safe and innocuous nutritional treatment which has, in my own experience, caused neurologic improvement in about 200 of my MS patients. So there is a very long list of obstacles that we have to face, and now, of course, we have got the HMOs and things of that nature which mean that the people aren't going to be reimbursed. Not reimbursing for chelation therapy, which has been really the mainstream of cardio prevention for thousands of physicians who practice CAM, and so this is not reimbursed by Medicare, and therefore the major insurance carriers don't want to carry that reimbursement. Many states, of course, have different laws. New York State, we finally got a law passed which acknowledges a physician's right to practice alternative medicine, and in so doing, they no longer can just take our license away just because we do things differently. I think the important thing is that having a right to do things differently is very important. You asked me what the problem is. I want to talk about the solution because the solution would be to get the kind of research done that would allow people, the government and other people of interest, to see the two systems compared with a matched group of subjects to see whether or not our assertion that we get better results and at a lower cost than mainstream medicine has been getting.

DR. GORDON: Thank you very much. Tony, Bill, and Tom.

DR. LOW DOG: Part of what we are trying to do is to determine access and delivery, and I just want to commend everybody, and I thank you also for bringing the nursing perspective which we had not really heard, and who, by the nature of their profession, are very holistic. But my question is really directed at Well Springs. It sounds very exciting, what you are doing over there. One of the things about access is who can afford it, who can pay for it. We have already discussed reimbursement, and that is going to be a separate session, really, but do you make attempt in your services for sliding scale fees? Do you have a day a month where there is a reduced fee schedule? How have you worked to address providing to the community for those who cannot afford $60 for an hour of service?

MR. ROSENTHAL: Couple of things. First of all, there are discounts available that a practitioner can offer to someone in need at any time. Secondly, we certainly encourage our practitioners, who generally work exclusively with us, to also work in some sort of giving back to the community environment. Obviously reimbursement is potentially the solution. You know, our prices are not that high, and I think the point about the cost of the payment exceeds the cost of the treatment, and even though people have an expectation to not pay for their health care, you know, spending $200 or $300 for a course of acupuncture that addresses a migraine issue you have had for years is pretty trivial. And, in fact, we don't have a great sense of household income, but we have done surveys of our customers. It is surprisingly low. This is not only an affluent community that comes to Well Space.

DR. LOW DOG: Could you give us an example, of like an hour of acupuncture treatment?

MR. ROSENTHAL: Acupuncture treatment is $60. You know, the intake is $85, and the treatment is $60. But you can go down to $40 if the need arises.

DR. LOW DOG: Thank you.


DR. FAIR: I have several questions for

MR. Rosenthal. First of all, you addressed a couple of times that Well Space is not going to represent integrative practice, but rather complementary, and since we are talking about access, I had questions relative to this. Since your clients really didn't their physician to be involved, first of all, how does that make it complementary? It would seem to me almost separate. Secondly, when you had that pilot project, 2000 people with the HMO, and only 70 took advantage of it. What recommendations do we have? What did you learn out of that? In 70 out of 2000, when it was a free benefit wasn't really impressive.

MR. ROSENTHAL: No, it wasn't impressive. I would say let's answer the second first. Right now, as I said, reimbursement is not something that -- obviously the costs go dramatically up, particularly when an HMO is trying to do something unusual, the costs are even higher. So you can imagine what the costs are. And the discounting is relative to a retail price. So literally for every visit, we lost money. But it was still worth trying. I think the message is that not that many people know about CAM or believe in it. The people who do will pay for it. But the people who don't, don't know about it. So there is certainly a policy goal of more education which would then make it not 70, but 700. It was disappointing. We expected an increased demand to at least be something we would learn from it. But I think education is the key thing. On the issue of complementary versus alternative, I mean we certainly established the company with the goal of it being complementary. As I said, we have full sub notes which is a pretty substantial cost. We can generate progress notes. We expected a lot of exchange on our initial intake for

MS. You would fill out your physician, there would be a check box, we will send the physician the note, and literally I think was zero people checked that box. So my point was not a matter of opinion, it was just a matter that the patients simply do not view them as connected. Maybe they don't view them as connected because they go to their doctor when they are sick, and they go to Well Space, at least to some degree, when they are healthy, or when they are sick of going to their doctor.

DR. FAIR: We heard a number of presentations yesterday that heart disease and so forth, the theme was always there throughout all these presentations, or for cancer, if only I had known about this before I got sick, before the defining event, I would have changed my life. I guess it comes back to education, but I wondered, it seems to me, and I said this yesterday, we are not doing a very good job in education. We have this epidemic of obesity and increasing risk of diabetes in people in their 30s, and it has been estimated that probably at least a third of cancers are diet-related, and another third are probably related to other lifestyles, and it seems like we are not getting the point across. So have you learned anything that this condition could say this would increase accessibility or acceptance of CAM, from your experience?

MR. ROSENTHAL: Certainly, again, it is not like we have an easy task of getting people to come from a preventive perspective. Generally speaking, people come when they have some issue they are going to address. We have tried to put programs together that are oriented to that, and they have not been wildly successful. So we don't have any real experience of that. I think education is a key part. There is an awful lot of preventive CAM and non- CAM treatments that are not reimbursed. Certainly that would help.

DR. FAIR: The last question. I commend you for the idea of the sub notes because that is so foreign to many of the modalities that are represented by CAM, and it seems to me a tremendous resource for outcomes down the road, although you say you are not sure what to do with them. But was that a system that you had to develop within Well Space, or was there a commercial system that you went to, to do that? Because that really is essential if we are going to get the information. That would improve not only research, but accessibility.

MR. ROSENTHAL: We did develop it based on an existing system. We created our own vocabulary and so you point-and-click with a TCM diagnosis and you point-and-click on the points, et cetera, as an example acupuncture being sort of the most different kind of system. We have 40,000 records that have got to be useful to somebody. But because there is not an ITD-9 code from a diagnostic perspective, because there is not a CPT code for the treatment, nobody knows what to do with it. And that may be because we are in Cambridge, you know, and Harvard is certainly the bastion of something in traditional medicine. But you would think that someone would be able to figure out something to do with our 40,000 records.

DR. FAIR: And these are all computerized, aren't they?

MR. ROSENTHAL: They are all computerized, and they are all reasonably structured. It is not free text.


MR. CHAPPELL: Mort, my question for you, I would like to understand better the decision that you made about complementary, not integrative, and then I would like to understand the compensation arrangements a little bit better for the practitioners. What were the driving factors for you to choose to select out MDs from the services?

MR. ROSENTHAL: There are basically three reasons. One was that we were concerned about hierarchy. You know, if you put a physician in, and it would be an exceptional physician who could practice literally alongside a CAM practitioner on an equal footing. But the physician would want to control the care, and we were dubious about whether any physician could really do that effectively. So we didn't want to create the hierarchy, point one. Point two, competition. If we had physicians, then conceivably we would get referral from other physicians and other practices. In Bottener, there are several clinics that do have physicians, and they have generally not done well. The third issue is we are an entrepreneurial organization, and we are trying to be successful. Sort of messing with reimbursement, messing with the traditional health care system is just not a good way of being successful. So we just decided to avoid it from that perspective.

MR. CHAPPELL: Do you revisit it?

MR. ROSENTHAL: With some regularity. And we have lots of physicians who would like to practice in Well Space, and we have a number of efforts or discussions to essentially put a Well Space inside of a health care system, but still sort of a separate box, with a door. On the compensation issue, practitioners are compensated about a third with salary and two-thirds with incentives. The incentives are largely based on number of visits, but there are also bonuses for utilization and for retention. So essentially we try to incent them to do a good job.

MR. CHAPPELL: I assume these practitioners are on the payroll and not on a referral?

MR. ROSENTHAL: Most of them are full time, but not all of them.

DR. GORDON: Okay, I have Don, Charlotte, Effie. Anyone else? And then David.

DR. WARREN: On that question about access, the access problem is that we can advertise alternatives and complementaries, but unless we have the practitioners to take care of those people, what do we do, to the nurse? I see a big chance for nursing to educate the physicians and make it their idea. Many times you go in and you try to beat somebody up with this, they go up the wall. But if you can slowly integrate it, and I see the nursing as the fastest way to integrate complementary alternatives into medicine, it could make it the physicians' idea through the back door, kind of. What do you think about that?

DR. ELIOPOULOS: Well, I think nurses have educated physicians for a long time very tactfully. I would like to not put it in the framework of a manipulative, that we are helping the boys understand this is their idea. I really think we are in a partnership. And I think part of our education is to educate about a new model of care delivery where the leader of the team does not necessarily have to be a physician with this integrative model. I think that takes perhaps a bit more than education to make that happen. What I am hearing about in some of these other models, I have to question if maybe people don't want or haven't asked for records to be transferred because of the lack of education, because nobody sat down and helped them understand that there has to be a marriage of these therapies, and I think nursing does have a crucial role with that.

DR. WARREN: Well, I see patients not wanting records because they don't want to be insulted at their doctor's office. You know, to take those records and say I am using this nutrition, and all of a sudden they are lambasted because they just make expensive urine.

DR. ELIOPOULOS: And I think that is why it is important, and I think this is where nursing can play a vital role, because nurses are in these private practices with the physicians, and they are in the hospital settings and elsewhere, to be able to buffer some of that, to provide some of the education, to be able to sift out what is a fantasy here versus what is a real therapy that can be effective.

DR. WARREN: So we are dealing with a lot of frail egos.

DR. ELIOPOULOS: We are dealing with some of that, yes. [Laughter.]

DR. WARREN: Thank you.

DR. GORDON: Okay. Charlotte. SISTER KERR: This is specifically to Charlotte. Thank you for your presentation. Aspects of CAM are integral to nursing, touch, listening, time. The nurses were the first to know that self-care was primary care, or at least equally with the others. I also notice that historically, and it continues to be, and I still don't understand why, nursing is even being in many ways still marginalized today. There is a crisis in nursing. And just as I was listening to you, I thought, you know, as nursing is seemingly getting to be more of a crisis and being diminished, CAM is rising. Historically it seems like the nourishing functions, the yin functions, the affective functions, the listening functions, is what we have refused to pay for in health care, at least in the experience in nursing. So having said all that, I wondered what could you offer, what could you envision, what coaching do you have to give to us, both in the area of CAM and even policy, based on your experience in nursing? And if not now, later. And very specifically. Because you have been there and we got this.

DR. ELIOPOULOS: And it may be that I will need to come back with some recommendations to offer some specifics. You know, I do think that some ongoing advocacy for the fact that it is a healing process, it is not just really throwing modalities into the pot. Now those modalities are important, and the reimbursement for them is important. But there is a process, a healing process, that needs to take place, and at some point we have got to put the rubber to the road and say we are going to commit to this and reimburse for this, or we are not. Or are we, as I say, just have additional fragmented care, using a different set of modalities in the pot? You are right with what you say about nursing. We are having a crisis, and I think it is because we cannot function in the healing arts as many of us have been nurtured into a profession to believe that is unique to us. I think our association manages to attract people who are frustrated with the conventional health care practices, and want a different path, want a different practice, and are carving out some unique practices to make that happen. But unfortunately we are tied into systems where our paychecks come from some pretty conventional sources and dictate what our practice modalities look like. SISTER KERR: Thank you.

DR. Atkins, when you spoke, you actually gave a preface, in my opinion. You were talking about paradigm shift. And you said there was a new definition of system of health care. Charlotte, what you are saying is talking about the need, as I often say, acupuncture is a process, not a procedure, and you were speaking to that in terms of what we are about, not just adding on new modalities. My listening at the moment is speaking to the fact that we need to, perhaps, as

DR. Atkins said, is continue to have a conversation, and we are talking about what we are about here, is to talk about are we talking about a change in the system, or are we talking about -- do you think that that is important, that before we talk about the reimbursement of this or that, that we need to actually speak to that in our education to the public about what we are about here? Would you agree with that? Or

DR. Atkins, you are shaking your head?

DR. ATKINS: Absolutely. I see no reason why the practitioners of mainstream medicine don't begin to add more and more complementary therapies into their thinking. I really think that there has to be a whole movement away from specialists to the ultimate idea of a generalist, a person who knows everything. I think that is a noble ambition for a doctor to try to achieve, and I don't think it is difficult to do. I think it is quite possible that a doctor begins to learn if he can't do acupuncture, he knows the role that it plays, he knows the role of all the herbal therapies, he knows the role of the nutritional therapies, and he makes decisions on the basis of what will be the best choice for this particular patient. That seems to me to be the only direction which will change the way medicine is practiced for the better in the future. If we keep them separate, if we keep the alternate treatments separate from mainstream medicine and allow mainstream medicine to proceed in its direction of making us the nation with the highest health care costs in the world, and they are doing that because of financial considerations, I do believe. When surgery is being offered before you give a person a chance to reverse the heart disease, to give an example, that is money. Complementary physicians specialize in reversing heart disease once people have been told that they need a bypass, but to do the bypass before they get out of the hospital is the problem. I think we have to confront the mistakes that are being made by my colleagues in mainstream medicine, and complementary techniques are the answer. They are the potential answer, the potential way to prove to everyone that this is the way medicine should change over the next few decades. I think when that happens, we are going to be very surprised at how health care costs go down, how hospitalization statistics go down, and how we will be able to handle all the Medicare problems that we are so concerned with, because they won't be quite nearly as expensive. SISTER KERR: Thank you. One last follow-up questions. You said -- I'm sorry, I forgot your name for a moment. You said, of course, reimbursement is the solution and will enter into reimbursement, although in your paper on policy recommendations you mention that the best practitioners with the best outcomes don't necessarily choose reimbursement. I want to suggest that maybe reimbursement is not the solution. What do you think about that? My experience is it is such a botch-up, and --

MR. ROSENTHAL: The existing model of reimbursement is clearly not the solution, and some sort of subsidy, conceivably, for people who cannot afford care may be the solution, or medical savings accounts with the subsidy at the low end. Again, a range of things. Certainly for existing models of reimbursement, from an administrative perspective, do not work for CAM, period. They really, really don't, and the idea of negotiating a fee, again, remember, traditional medicine before managed care was say seven times what a doctor took time. They were billed out at seven times. There is a lot of room for administrative cuts, there is a lot of room to negotiate the fees down. When you are billing out at one and a half times what is a not very high salary and you want to discount that, where are you going to go? You can't take costs out of the operations, so therefore an acupuncturist with five years of experience, instead of making $45,000, if they are still doing it, is going to make 30? That doesn't seem right. So I don't think reimbursement is the right answer. SISTER KERR: Thank you.

DR. GORDON: Effie, and then David.

DR. CHOW: I also want to thank you for the report, and my question is directed towards the nursing. I appreciate the role of nursing and the role that we can play as mother, father, and companion, and overall role. One of the aspects of nursing is that we are also facilitators, and networking, really creating the ambience for healing and caring to take place. I wonder if the American Nurses Holistic Nursing Association, what is your role at working with other organizations, like the American Holistic Medical Association, or even American Nursing Association, to facilitate better in terms of eligibility and even education and so forth?

DR. ELIOPOULOS: We have just started. It has actually been a week past in terms of our networking with some of the other organizations. We do network with other nursing organizations, and there is the umbrella of the NOF and the VASNO umbrella, nursing organizations, especially organizations that do meet regularly and exchange, and we actively participate in that. We share our views with those organizations and exchange programs and thoughts with them. We are developing a position paper. We have a draft of a position paper on the nurse's role in complementary and alternative medicine that will be shared, and hopefully endorsed by all these nursing associations by this time next year. So that networking within nursing is stronger, I think, than with the AHMA and some of the other associations. We have started conversations with them about doing some joint educational conferences and exchanging materials, but that is about it. We have not taken a stand together for positions. It has just not been the way our associations have functioned. Not out of a lack of desire. I think it is been out of a lack of organizational, administrative strength.

DR. CHOW: I hope that would be something you would consider.

DR. ELIOPOULOS: It is a goal now. It is certainly something that is important to us.

DR. GORDON: David.

DR. BRESLER: This is for

DR. Atkins. We are talking about access, and it seems to me no matter how large your facility is, there are still just a finite number of people that can come through your program. However, you have leveraged your program by writing books that takes at least part of your program out to huge numbers of people. However, you have no interaction with those people in terms of being able to do lab testing and the other things that you do in your facility. How comfortable are you with using books and print media as a way of getting greater access to the information you use in your program?

DR. ATKINS: Well, I don't consider the books a way to get access. I hope they will get people to make a phone call, and then we work out a system. Sometimes we have quite a system of nutritionists who can do a lot of telephone consultations, but that is inadequate. I think our greatest contribution are seminars we hold for physicians who would like to learn our kind of medicine. We expect that each year when we hold one, we expect to get a much larger group. We are pretty certain that there are more and more physicians who are going to practice this way. All we have to do is remove the fear that their license will be revoked, and once we do that, the doctors want to do it. It is absolutely amazing. When we put out an ad for staff physicians, more and more people respond, and these are people who really don't have training in alternative or complementary medicine. They just want to learn it. And then more and more people attend our seminars, and we are not the only ones to have seminars. Quite a few other seminars are held, and more and more people join. More and more people seek membership in a group like ACAM, the American College of Advancement in Medicine who are over 1000 members now. So I think the access is going to be through more and more physicians who emulate the people at our center, only practice in their own towns, their own cities, their own states, and I think that will be the answer.

DR. BRESLER: Thank you.

DR. GORDON: Wayne will be the last questioner for this panel.

DR. JONAS: I had a question really to

MR. Rosenthal and to

MS. Eliopoulos. There are a number of models of nurse management in conventional care, especially oncology where nurses kind of become patient advocates and are the communicators between the radiologist and the oncologist and the primary care physician, and looking for clinical trials type of thing. I am wondering, that type of a model as a health educator or coordinator of patient care, is that something that either of you have talked about in your organizations or considered? Is there a need for it? Is there something that patients would like, or only a certain percentage? Does that look like a way of kind of at least bridging a link between these what appear to be two fairly parallel systems that don't communicate very often?

MR. ROSENTHAL: We have a function that we call Well Space Guide, where again when we were setting up the company, the assumption was the guide would be sort of the gatekeeper for a lot of clients who were coming in and didn't know what to do. In reality, the guide is requested or used maybe by less than 5 percent of our visits, and really only when we force it, like we have a back and neck pain program where you have to see the guide as a sort of starting point. And so that is surprising that it was so little. In other words, it is mostly people who know that they want acupuncture or know that they want to see a naturopath or whatever. We considered and interviewed some holistic nurses for that, and certainly the idea of a nurse playing that sort of bridging role would make a lot of sense. Again, it has not been utilized very well. We ended up hiring someone who is an acupuncturist/massage therapist/occupational therapist, basically has a range of skills. But mostly it is around, you know, connecting to a patient in a very sort of easy way. But certainly that would make some sense, but it is not a huge demand.

DR. JONAS: In your population, people kind of know what they want and they come in, and they seek it out individually. I imagine, though, in other groups, for example, oncology patients, patients with cancer, or if there were to be an effort to make this more proactive to provide access to a wider population that did not have kind of this knowledge, that perhaps that might be more important in those circumstances.

DR. ELIOPOULOS: That is what I would like to respond to, because there are some nurses who are developing that kind of practice, both as a private practice as well as within some conventional settings. I know I have a limited private practice myself where I perform that kind of service for people with chronic conditions. And what I find is that I am working with a lot of people who don't know what they don't know, in terms of what options are out there, both within conventional medicine as well as some of the CAM modalities. So my role is to help educate them and refer them to practitioners, and to monitor what is going on, and to make sure that one hand knows what the other one is doing. I think it is a very viable role for nursing.

MR. ROSENTHAL: It is not like people coming in knowing exactly what they want. We have a relationship, for example, with a large cancer support group in Boston. We speak there regularly, so they come in through that door, and they are referred to a practitioner who may be particularly good at a condition.

DR. JONAS: Thank you.

DR. GORDON: Thank you very much. I want to take just a couple of things. One is that I really appreciate the questions the Commissioners are asking, as well as responses. I feel like we are really getting to some of the issues. I would encourage the panelists, and all the panelists who come today, that out of the questions and out of the dialogue we have, to really think on as large and ambitious and hopeful a scale as possible about some of the issues that we are all discussing, and to make recommendations to us based on what is coming out of this experience, as I think especially these last few questions were pointing out. We are really looking to see how this health care system can be responsive to people's needs and far more effective, and our task in a sense goes way beyond attention to CAM. The other thing that I want to mention is that we have an hour at the end of the day, Charlotte, to address some of the questions that you are raising. I think it is really important that we be thinking about these as well. Tom and Joe.

MR. CHAPPELL: May I ask one question of the panel?

DR. GORDON: Okay. But we really have to move on because we are already a little behind.

MR. CHAPPELL: Mort, are you finding branding to be successful, or a successful way of economic sustainability, as opposed to reimbursement?

MR. ROSENTHAL: That is say a consumer coming in of their own choice. Yes, I would say our problems are not in creating consumer demand. We have a good brand in the Boston area, and it generates a fair amount of visits. So I would say that in our case, branding is sufficient. I also wanted to invite any of you who happen to pass through Cambridge to come to Well Space, because we are a delivery system which is bricks and mortar, and actually seeing it is interesting.

DR. GORDON: Joe, did you want to say something?

DR. FINS: Just a question for

DR. Atkins. In your statement that was supplied to the Commission, you talked about informed consent, that you wanted to follow the recommendations of the New Jersey Supreme Court, saying that conventional practitioners have to provide patients with information about alternative therapies. Let me really turn it on its head and just ask you about access and safe access, and the safety issues. What happens in your program when a patient fails your modality? I am sure that there failures in allopathic medicine, and there are failures in complementary modalities. What kind of safeguards are there that that person has access to the conventional modalities and is quickly and appropriately referred to a cardiologist, perhaps for bypass? What kind of mechanisms have you guys used to ensure the safety of patients in that situation?

DR. ATKINS: Well, basically, all of us are trained as physicians, and whenever we see a problem that we think requires the need of someone whose specialty allows them to handle it, we make the referral right then and there. So we have never gotten into that kind of trouble because we refer things out whenever there is the need to do a referral. So it is something we haven't had to deal with. Remember, you have to understand that, yes, we add complementary therapies to our program, but we are basically very well trained internists, and our instincts are those of a well trained internist.

DR. GORDON: Great. Thank you again. We will take a five-minute break and then we will have the next panel. [Recess.]

DR. GORDON: Will the panelists please come to the table. Thank you very much. Again, as you will see when you look at the schedule, this group of panelists will be focusing on clinic situations in which they play a leadership role, and they will be presenting the models of CAM or integrative care that they are offering. First will be Tom Trompeter. Good morning, Tom.

MR. TROMPETER: Morning. Thanks for this opportunity to speak with you once again. Before we get started, I know that when we were in Seattle, a number of you asked me some questions that I said I would get back to you on. November is usually a rather busy month. We have got a couple of major grants that we do in the early part of December, so that was really kind of occupying our time. But I will provide you with answers to those questions, either on kind of an ad hoc basis today, or in writing, in a more formal way, some time between now and the middle of December. You all posed four questions, and I would like to just kind of run through them, not quite verbatim as it is in your book, but as a way of sort of starting the conversation. My name is Thomas Trompeter. I am the executive director of Community Health Centers of King County. We are a private non-profit, tax-exempt organization, with a consumer majority board of directors. What that means is 51 percent of my board of directors is comprised of patients of our health centers. We have six medical and four dental clinics in suburban Seattle, probably comprising about 50 miles between the two furthest ones. Each year we provide about 90,000 visits for people who are all poor and primarily uninsured. About 95 percent of our patients have family incomes that are below 200 percent of the federal poverty guidelines. About 75 percent are below 100 percent of federal poverty guidelines. A little over 40 percent of our patients have no insurance at all. Those that do have insurance are generally insured either by Medicaid or by what in Washington is known as the Washington Basic Health Plan, which is a managed care product designed for people primarily with incomes below 200 percent of poverty, who pay premiums on a sliding scale. When you all asked why and how did we decide to provide CAM products and services, I think context is also key. The Puget Sound area, I think, has for a long time been a rather fertile ground for integrative medicine and, in fact, not just our corporation, but the other community health centers in the area have had intermittent experiments, I guess is one way to say it, in providing integrative care. At various points in time over the last 25 years, various health centers have tried to employ naturopathic physicians, for example, although economically it has not always worked out. In 1995, due to some advocacy work that was being done throughout the community, an opportunity was created for us to compete for a grant that would help us establish an integrative medicine clinic, and in that process we developed a partnership with Bastyr University which is, I think, well known to most of you, to begin an integrative clinic. What we did was we basically proposed a response to a request for proposals that had three components. One was that it include conventional primary care, another is that it include at least some elements of complementary and alternative medicine, and the third component was that it include an evaluation component. We successfully competed for that grant, and that is what really got us off the ground financially to start this clinic. We opened our doors on October 21st, 1996. Secondly, you all asked -- and actually, I would like to back up a bit. There was a fairly firm commitment from our board and from our administrative leadership to pursue integrative medicine, and I think that really helped set some organizational context for us to move forward on this. We don't move in policy directions like this without the approval of our board of directors, and it was very critical for us to have a consumer board interested, supportive, and actively involved in this process, and they were. In asking how do we determine which products and practices to make available and for which conditions, on the which conditions side, I would just like to say we are a primary care operation, and the conditions for which we offer CAM services are the conditions for which people normally seek primary care. We have referral relationships with specialists and hospitals, and we do use those for folks who present us with conditions that are beyond our scope of practice. When we responded to the RFP for the King County Natural Medicine Clinic, the clinical leadership from both Bastyr community health centers, with input from our administrative staff at both organizations, identified four disciplines that we would include in the initial organizations. Those disciplines are naturopath medicine, acupuncture, chiropractic, and therapeutic massage. In addition, we decided initially to offer naturopathy and acupuncture on site and to offer chiropractic and massage via referral. The decision to offer some services on site and some via referral was driven by two main concerns: the need to use limited resources wisely; and the need to offer in- house those services for which we all felt that we possessed sufficient expertise to be able to provide appropriate quality assurance. That is, we could not afford to offer all four on- site, and we wanted to be able to do on-site that which we could do best. For chiropractic and massage, we would then establish contractual relationships with community providers, whom we trusted, to be able to provide not only high quality care, but who would also have the necessary non-clinical skills to provide care to the particular patient populations that we serve. Just as a sideline, a little over 30 percent of the visits that we provide require the presence of an interpreter. This is not the norm in the private practice. We had hoped that over time we would gain the necessary skills and necessary funding to provide both chiropractic and massage on site, and in one small step, in May of this year, we hired a licensed massage practitioner to provide on-site therapeutic massage via referral from providers throughout our system.

DR. GORDON: Tom, I think what we are going to have to do is, we have read the testimony, and we will have a lot of questions during the question period. Sorry to cut you off.

MR. TROMPETER: That is fine.

DR. GORDON: Next will be Sylver Quevedo.

DR. QUEVEDO: Thank you. My thanks to you all for this opportunity and to you for your pioneering efforts in this area. My name is Sylver Quevedo. I am a physician and nephrologist and the director of the Center for Integrative Medicine at the O'Connor Hospital in San Jose, California. I come to you very much from the perspective of a conventional physician in practice and also involved with the teaching of medical students, residents, and fellows. I have five points, and I will be brief. Integrative medicine is the medicine of the future. Any hospital not looking at it will be seen as obsolete within 10 years from now. The second point, conventional bio-medicine needs the broader perspective of integrative medicine to thrive. These are bad times for hospitals and academic medical centers, as many of you know, and the broader perspective of integrative medicine will be revitalizing for the conventional ranks, and it is necessary. Integration is essential, and it is largely occurring even by virtue of the process we are engaged in today. However, programs which look at it up front and take it seriously will have an advantage in the years to come. Culturally appropriate care is predicated on a respect for the life, world and culture of a given patient, and integrative medicine takes this perspective seriously, not relegating it to the realm of psycho-social factors, as often happens in the narrow bio-medical model. Belief matters, and this perspective, I think, is honored in the integrative medicine vision. Lastly, credentialing strategies are essential for hospitals and academic medical centers, and they must be led by physicians with standing on the medical staff in order to be successful. Let me elaborate on a couple of these points in the time remaining, but again, I will leave most of this to the questioning period. The first point, that integrative medicine is the medicine of the future, in the materials that I have provided for you, I took some pains to spell out what we mean or what we meant in our efforts by integrative medicine, and they were not limited to a discussion of a given modality, but attempted to reach the deeper traditions of medicine and the healing traditions around the world. We drew on the work of

DR. Gordon and others, and worked hard in our discussions to make it our own, to understand it and articulate it for our own groups. This is what I mean by integrative medicine being the medicine of the future. It is, I think, incumbent upon us to look deeply at what we are doing in conventional medicine, asking questions about why it is no longer seen as effective, why is there such great dissatisfaction both among practitioners and patients alike. Regarding conventional bio-medicine, as powerful as new technologies and scientific advancements have been, the broader perspective of integrative medicine brings us back in conventional bio-medicine to the larger cultural process of which we are a part. We can no longer simply be about the business of medicine or science without paying attention to the larger cultural forces and, indeed, the perspective that many consumers have, that there is something much greater than science when it comes to healing. Lastly, culturally appropriate care in our increasingly pluralistic society is a necessity, something that we need to look at very hard, something that, without taking it seriously, will simply make what we do in conventional medicine less and less effective. And in order to do that, we need to think in terms of the broader culture and the healing traditions from the cultures that patients come from, and to realize that belief matters very much. We are no longer regarding it as an afterthought. It needs to be brought into the main stream of conventional bio- medicine. This should be part of what occurs in medical schools and medical training progra

MS. Lastly, regarding the credentialing issue, it has been important for us to work actively with members of the medical staff to develop a strategy that they could feel comfortable with, and I will simply conclude by saying that initially much of the resistance that we encountered from the medical staff was simply based on the fact that they had very little familiarity in these matters, and as we began this dialogue, that resistance has largely melted away, and they are now asking us to organize a department of integrative medicine in the hospital and to bring these therapies into the in-patient setting. Thank you.

DR. GORDON: Thank you very much. Woodson Merrell. Good morning.

DR. MERRELL: Thank you,

DR. Gordon and other members of the Commission, for the chance to be here today. I was actually told that I would not be presenting any remarks at the beginning, so my remarks will be fairly brief. I would say that with

DR. Quevedo, I feel like we must have been separated from the hip in terms of many things we have to say about the philosophy and background of medicine are very similar, particularly the aspect of integrative medicine being the future of medical care. I am just going to mention a few things in terms of the direction of my questions that I was given about the Academic Centers incorporated integrative medicine. In terms of that background, I am the executive director in New York City of the Beth Israel Medical Center's Continuing Center for Health and Healing. This is an integrative medical center that was in planning for about two and a half years, and just opened in June of this year. It comprises 16 clinicians, nine physicians, and seven allied health and CAM providers, covering most aspects of integrative medicine in a hospital-based practice. The hospital held a think tank about two years ago, and they actually got it, they understood that this is the future of medicine, and the patients are increasingly using it, that they don't know really what to do for many of the therapies that they are using, very few reliable information sources. Someone is going to do it, and it might as well be them. So they put together a team of people to set up an integrative medical center that would be academically based and that would combine the best of the traditional healing practices that have been around for centuries or millennia, look to them to be increasingly evidence-based, and combine that with the best of conventional western bio-science. There are many complementary medical centers in academic settings around the U.S. The majority of them are primarily research and education, or they have clinical programs there that are very small ones, primarily focusing on mind-body. Not that that is not important, and of course it is the most important aspect of the field, but I think there is a lot of trepidation in terms of incorporating any of the other aspects of CAM into traditional academic settings. At Beth Israel Center, we actually have all aspects of research, education and clinical care on an equal sway, and we provide the patients access to most all treatment modalities and approaches within CAM. We are part of an academic hospital setting. Beth Israel Medical Center is a teaching hospital of the Albert Einstein College of Medicine, and it is actually very, very focused now integrating integrative medicine into all aspects of training. The medical school itself just had its first working group with the Dean of Education and the Dean of the Medical School committing to integrating integrative medicine teaching into every course of all four years of medical education at Einstein, and we so far have been able to do that for about half of the courses, and after our first meeting. We are incorporating the medical students in all four years being able to rotate through our center and the residency progra

MS. At Beth Israel, we actually have the nation's first required residency rotation in integrative medicine, which is a one-month rotation in the family medicine department as a template for trying to train not only medical students, but physicians right now in training, because of course a big part of the problem is that even if you wanted to deliver these services, who are the practitioners that should be delivering them. There are very few people who are trained in aspects of complementary medicine in any kind of an organized fashion. So the third part of this, besides medical student and residency education, is fellowship training, and we just received the funds to set up a two-year fellowship in integrative medicine at our institution, and we will be working with Andrew Wyles Fellowship to really try to set, through fellowship training, what are the standards of what an integrative physician actually does in practice. One of the things that the focus of this group here today is about is access. We are primarily a private practice model, and we may not have time in this session to get into it, and I know the next people will be talking about it more. But it is very difficult, in terms of the current managed care system, when you are reimbursed 30 cents on the dollar, when your overhead is 50 and 60 cents, to make a go of it. So our clinic is primarily fee-for- service based, with prevailing rates for faculty-based practice. We do have a number, though, of access points for people who are uninsured, or underinsured, including what we call a Helping Hands Fund. Right now we have raised $50,000 to provide free care for people who don't have medical insurance. We have a number of other clinics, they are Title 28 clinics, within the medical institution. Fortunately, Beth Israel who for the last decade had been providing CAM services to the underserved and minority populations, and although through the fellowship and research programs, we will be able to provide access to patients at a reduced fee. Our fellows will actually be paid a small stipend for the patients that they actually see, and these are board- certified physicians in primary care who will be able to see patients at a reduced rate. The last point I would like to make before I close is the role of CAM providers, the integrative knowledge of the physicians being knowledgeable in integrative medicine in terms of practitioners working together. We see it as critically important that most licensed fields of CAM be, if not all licensed fields of CAM, be incorporated in these centers, particularly an example being chiropractic. I personally feel that chiropractic has an important role to play in integrative medical systems, not only because of the services that they provide, increasingly. Over the last decade, as patients are becoming disenchanted with the medical care system and their physicians, they turn to CAM providers. I can't tell you how many patients that the chiropractors, as their primary care doctors -- bringing chiropractors into the primary medical care system -- actually allows those patients to come back into the traditional medical care model. The role of nursing I will discuss a little bit later. Panel Discussion

DR. GORDON: Great. Thank you very much, Woody. And for somebody who wasn't prepared, you did a great job. Thank you all three. It is a tremendously fertile field for us to explore. Who would like to begin with questions? Conchita, and then Joe, and then George, and then George.


DR. Quevedo, I would like to find out what some of your specifics are as far as the culturally appropriate medical care that you use in your clinic.

DR. QUEVEDO: One of the most important things to address in this issue, I think, is language. Now our particular program at this point in time is in a community hospital, it is a private hospital, and we have seen many new patients with limited resources, but it is not the same, for example, as the hospital I was at just before, which is the County Hospital in San Jose, where we did see many patients that are indigent, et cetera. But having said that, I think one of the most important things is language, but it is not only language, but also belief syste

MS. I think the important point I would like to make to you today is that we used to think in terms of culturally appropriate care as a problem for a given ethnic group or racial group, et cetera, and I would simply like to suggest to you that all of us operate in a given belief system, and that belief matters. This is a perspective, I think, that has been forward by integrative medicine, understanding, for example, mind-body connections, et cetera. It is revitalizing because it takes us out of a narrow sectarian dialogue and into a much broader dialogue which is more fundamental, and I think more compelling for the future.


DR. FINS: I just think it is interesting to note a paradox here, that the for-profit entities that we heard of this morning that are outside of the mainstream reimbursements mechanisms are more viable than you guys who are trying to do it within the appropriate back-up and physician interaction. For example,

DR. Quevedo, you have a screening by an internal medicine doctor before any referral occurs, which seems to be very prudential. I would just like to ask you and

DR. Merrell about this paradox and the similarity that mainstream academic medicine has, that the cost of providing care in those settings is more expensive. So what kind of funding strategies would you recommend to allow the integration, which I think provides added value and ensures safety? Either one of you, or both of you.

DR. MERRELL: I think it is very difficult for these centers at the moment to exist without private funding, and I think certainly governmental grants are good, but it takes a long time to get them, whether it is for research or other progra

MS. Private funding sources are really the white angels of this field. We wouldn't have been able to do it without being funded privately for start- up and operating for the first year. You can't possibly make money for a minimum of three years in most business plans, and increasingly medical centers are no longer able to foot the bill for this. So I think looking to private funding and developing those sources in the community is a critically important area. One thing that our institution did that I am surprised, but it apparently is unique to most institutions, is have the hospital recognize the importance of what we are doing to the existence of the medical center, and to the medical care system. They actually made this a part of the mission of the hospital, to develop integrative medicine services, and thereby they threw open the doors of the development department, so that the trustees and donors lists were given to us and they were actually courted by the development office with us, to bring additional funds in. Seeing it really lessens turf battle between the departments, because this is coming into one big pot for the institution of the whole. It is going to help it as it makes its transition from hospital-based to more ambulatory- based care in the future.

DR. QUEVEDO: I would just mention a couple things. It is certainly true that we are doing more than just taking of patients and developing progra

MS. We are working on the institution, and we don't get paid for that, and that is a lot of work. There is another perspective, and that is that we have argued with the hospital that there is a value added to what we are doing, that it is changing their image in the community, et cetera, and that has worked to some degree. But admittedly it is hard to do this kind of work in these institutions with so much institutional inertia, heavy overhead requirements, and cost burdens, et cetera.

DR. FINS: Do you guys feel that there is an uneven playing field, that you are providing more and yet you have to compete with people who are not providing all these services, and yet in the marketplace you are competing against some of these other venues?

DR. MERRELL: I wouldn't put that in a proprietary model because it is based on whatever the funding source, venture capital, whatever. I often wanted to open a center, franchise it, et cetera, not that proprietary centers don't have a place, but certainly when you don't make the bottom line, usually the first things to go will be research and education, and then shortly after that all of a sudden you are going from your average 22 minutes per visit to let's ratchet that down to seven minutes a visit, pump up the volume, we need to make some money here. And I think that academic centers provide a little bit more cushion in terms of looking at the mission to be a global mission. Of course, the bottom line is important, but it is on equal footing with other aspects.

DR. QUEVEDO: We actually deliberated three scenarios that included a venture model, a joint venture with the hospital and a private group, and as part of the hospital. And for many of the reasons similar, we decided not to go in a proprietary mode.

DR. FINS: What about the budget for your commitment to furthering the research and educational needs of this developing area? Thank you both.

DR. GORDON: George.

DR. DeVRIES: Thank you.

DR. Merrell, most academic medical centers are not including chiropractic at this time, and yet that has been somewhat unique in including chiropractic in its integrative clinic. And not only that, you indicated that it is critical, that chiropractic is playing a critical role in your clinic. Can you expound on that, especially if there are issues of access, like what patients you are attracting because you offer chiropractic, or other variations that you see?

DR. MERRELL: I wouldn't say critical is the right word. I think it is very helpful to have chiropractic involved. I mean similar care could be administered by osteopaths, for example, but chiropractors do have a unique role to play, and they are often as team members of the community. So I think incorporating them into the system provides an important modality. There is no doubt about the fact that there is an incredible entrenched opposition to including chiropractic. It used to be the same way with acupuncture, but that is considered almost more mainstream now. It seems to be a no- brainer, where five years ago I thought if I even mentioned it at my medical school, I would have been booted out. It has been quite a change. I think that it is institution by institution. It is really the luck. I mean what you are able to depends upon which people in key places have had personal experiences that have transformed them, or understand, for whatever reason, the importance of this field. At our institution it happened that the Chairman of Physical Medicine and Rehabilitation thought chiropractic was an important modality to look at, and to have the services available, and so therefore helped champion it through the credentialing committee. We have actually developed credentialing guidelines you have in your packet that I provide you, the first guidelines in Academic Center in New York, to have a credentialed chiropractor, acupuncture, massage group within an academic setting that was developed by a committee that consisted of the Chairmans of Medicine, Surgery, and the resident curmudgeon skeptic who would, if he signed off on it, everyone felt that this was something that would be acceptable. There was a lot of hammering out in terms of language and scope of practice. But some institutions just won't be ready because the orthopedists, or whomever, there are large groups that won't allow it to happen. But it is something that I think increasingly will be looked at more favorably.

DR. GORDON: George.

DR. BERNIER: I would like to ask

DR. Merrell in terms of the educational programs that you have been able to put forth, you clearly have an integrated educational program in terms of CAM practitioners and traditional residents. Have you looked, at the same time as you have been doing that, at integrating the educational programs for the more traditional health providers, like nursing, allied health? Is that folded into one program?

DR. MERRELL: It is beginning at the medical school, primary medical school education, but particularly at our institution, nursing plays an equal role in terms of educational access. I mentioned, in answer to one of your questions that you gave me, that really nursing plays a critical role, particularly within the hospital, and so they are the ones who are on the front lines, who will help really to transform the institution. Physicians often don't have time really to do this, and partnering with nursing is very important. Medical schools are realistically more difficult to develop joint programs with, with nursing, with dentistry, or physical therapy or other allied health progra

MS. I think within the hospital or the medical center, it will happen first before it actually becomes capable of being integrated in the medical school setting.

DR. BERNIER: If I could ask

DR. Quevedo, do you have educational programs built into your enterprise?

DR. QUEVEDO: Not to the extent that

DR. Merrell does. We do have medical students who have rotated with us, and we do have a relationship with the family medicine residency that is part of the Stanford Medical School. But that has been informal. We are actually involved in discussions with the department, actually the Division of Family and Community Medicine, about the possibility of a fellowship that would be after family medicine residency training, a fellowship in integrative medicine. At Stanford, the family medicine activity is a division in the Department of Medicine, and so what we are talking about is a fellowship which would be a training program in that division.

DR. MERRELL: I just have one quick thing to add about our nursing. In our center, we have a nurse practitioner who is a solo practitioner, who also works beside being family medicine and Ayurvedic medicine, but we also have a clinical nurse specialist who actually is a person who provides what I would call holistic consultation. So when patients come in, if it is unclear whether they should be in our system, she is kind of the point person for doing a consultation to decide where they should access which care, if they are going right to the physician or, in our system, a patient does not have to see a physician first, they can go directly to a CAM provider if they so choose, and it is often the nurse who helps them figure out, based on their history, where they might need to go. So we see that as a kind of focal point of information for patients in triage.

DR. BERNIER: Thank you very much.


MR. CHAPPELL: With regard to access, could I ask the gentlemen who have the medical hospital model, can you assess competitively in any way, or have you assessed competitively in any way what were the consumers' interest in coming to the hospital versus a private entrepreneurial option, or other options? Another option, the community model? Do you have any idea how appealing your model is?

DR. QUEVEDO: Well, I would say we haven't done a formal study on that, but I can give you some impressions. One thing that we have found is that many patients who are already in the hospital community, whose physicians are at the hospital, et cetera, have been quite happy to be able to explore issues in complementary medicine, et cetera, with us since they regard us as part of the same community. Having said that, some patients are still nervous about talking to their physicians a lot about it, but they at least feel that they can address it with us and have us act as an intermediary, to some degree. But we also have many patients that are self- referred. When we initially designed the program, we had, largely because of considerations with the medical staff, had planned to have internal medicine evaluation pretty much for everybody. But there were many patients who simply wanted to come for massage therapy or more specific reasons, and who already had physicians who were very actively involved as their primary care physician. So we relaxed that, and we have patients who are self-referred as well. Whether they have chosen us because we are hospital-based or not, at this point it is hard to tell. Our impression is that it is important for us to encounter patients where they find themselves, and that is often in the conventional mainstream of medical care, and that is why we did it in the hospital. But I want to emphasize one other side to this, and that is that as much as we have done it from that point of view, the hospital and the medical community has been enriched by the activity, immeasurably. It has been revitalizing for us. Many of you know hospital committees that are really pretty sleepy activities. Our committee was one of the few committees where people were calling in advance to find out when the next meeting was, et cetera. So it was an experience in professional renewal for me, and I was really impressed by it, because I hadn't seen that for years in a hospital.

MR. CHAPPELL: Thank you.

MR. TROMPETER: I would like to respond a little bit. I think from the communities that we are in and our patients' standpoint, there is really no difference between what we are and what a private entrepreneurial practice might be, I think from an operational standpoint, and what motivates us. But, frankly, when we opened, there was a fair amount of outreach and publicity that was conducted both by us and others who were excited that this was happening. We had people coming directly to us that were coming to us because we had both modalities under one roof. It has been a very popular service with our patients, both those who have no money and no insurance, and those who do. And actually the economic mix of the folks who come strictly for the natural medicine clinic is a little bit different than the economic mix of the folks who come to us for other services. Not enough to make it a go on that alone, but kind of an interesting switch. The other thing that I think our experience and

DR. Quevedo's experience is very similar, we developed this rather elaborate protocol for informing patients of their options and their choices and ways of making sure that people knew what they wanted. We were open a month before we gave it up, because people absolutely knew what they wanted to choose. I think that that in itself was a bit of a bellwether.


DR. Merrell, do you find this much the same as your colleagues?

DR. MERRELL: Yes. I think that we decided to open in a facility actually outside the medical center physically, so we felt that patients would not exactly want to be streaming into a hospital in New York City to be getting CAM services. Also the quality of the practitioners, I think, is key, because unless you have high quality practitioners, preferably who are known in the community, you open a clinic in a hospital where no one really knows the practitioners in the community, it is very hard to get much volume of patients coming in. So we strove to find people who were very well respected in the community to bring into the center.

MR. TROMPETER: We have also found other corporations in the area have come to us and asked us to come and talk to them about how we have done what we have done, so that they can do similar things.

DR. GORDON: We have Linea, Bill, Charlotte, Wayne, and Julia. We have three minutes left.

MR. LARSON: Thank you. I will speak very quickly. This is probably a little bit of a conundrum, it is a conundrum for me.

MR. Rosenthal stated that they did not allow physicians to practice because of the reason of inability to not work without hierarchy, an inability to not be able to work alongside with other practitioners at equal levels. You,

DR. Quevedo, stated that it was important that a physician in good standing within the community be the director of this integrative clinic. Does that have to do with access to physicians who would be approving and supportive of the services, rather than the patients coming in and valuing a physician as the director?

DR. QUEVEDO: Let me understand. What I said is that for credentialing strategies to work, they need to be managed as an inside job, essentially, by physicians who are in good standing. Now let me preface this by saying that much of what we have done in contradistinction to Mort is that we have been working in a hospital environment, and that has mattered in terms of our strategy and our approaches. Let me also say that physicians certainly do need to change many of their sort of habits, but personally I have not seen them as resistant as it sort of appears from the outside, once you open this door. Practically clinicians and the people that are in practice, they are dealing with uncertainties and widespread consumer dissatisfaction, and they are really unhappy with managed care every day. I mean the time is right for them to begin thinking outside their box. So I think there is fertile ground there, but that dialogue needs to be marshalled by people to some degree that they feel safe with, and that is, I think, the role. Now admittedly, this is not necessarily what patients are concerned about. This is work for doctors with doctors. But my own belief if that they are an important resource, and if we have learned anything from this entire movement, it is that self-care, including healing the healer, is an important activity and professional renewal matters, and all of those things need to be managed as well. This is the part that I think has been good for us.

DR. GORDON: Before we go on to Bill's question, could you just give us a few words of description of what it has been like within a hospital environment? And even more importantly, what lessons you would have us learn from your experience working in a hospital.

DR. QUEVEDO: Again, for me, it has been enormously revitalizing. I have been around hospitals for most of my 25 years in medicine, and the last period has been enormously difficult, as all of you know. So personally it has been great. What has it been like the institution? The culture of hospital management right now is sick. It is a difficult culture to deal with. It is a culture that came out largely of the non-profit sector and is focused on expense and cost management, and is trying to deal with the new business culture that really doesn't understand. It is a culture that is searching for a new mission, and many people who are really doing the best they can, working very hard, but frankly, pretty burned out about a lot of things. So it is a difficult environment. But as I mentioned to another physician who asked me the same question, why do you want to bother with this, and I said the thing that is important to me about this is that physicians and hospital workers, et cetera, are an enormous resource. Amazing things go on every day, and they do amazing things and give unselfishly every day. If we can find some way to articulate a vision which gives hope and resurrects the feeling of joy in this work, reminds them of the sacred nature of our work, et cetera, that revitalization will result in an enormous outpouring of effort and work and creativity which I think will be sustaining in the future years. Beyond that, it is essential right now. These institutions are literally dying without it. So having said all that, there are some hard things. I was talking with someone earlier about the difference with what Mort Rosenthal is doing with Well Space, we are investing effort in dealing with the hospital and the academic medical center and nursing and physicians. I might mention one last thing, and that is that I think that holistic nursing is a profession which already has contributed, in fact, was pioneering in this effort, but in hospitals. If it takes its rightful place in hospitals it can be enormously important in the future, and we have tried to develop a model where we use holistic nurses as case managers to contribute to the effort to integrate and coordinate care.

DR. GORDON: Thank you very much. Bill.

DR. FAIR: Woody, thank you for your presentation, and I think you deserve congratulations for pulling this off, if you will. We are talking about access and delivery, but clearly underlying that is credibility. Unless the medical schools, the teaching hospitals, accept this as an integral part of medicine, I don't think -- I think the battle for credibility will be uphill, so I think that what you are doing is extremely important. Along that line I had a question. In the New York area, the Columbia Center opened and closed within a short period of time, and that is my entire knowledge of the mechanisms or the factors behind that, and I think the downstate program is sort of hanging on. So my question to you is from the apparent failures of those two academic programs, have you learned something, or is there something you could share with the Commission that would maybe influence our recommendations for stimulating the delivery of CAM services within academic programs, which I think is so important?

DR. MERRELL: I think there are two main reasons for the failure, and one was political, and that means relationships, and the other was funding. Each one had problems in one or the other or both, and there are other centers that have opened with great plans in academic settings that have also had difficulties. I think it is very important for relationships to be nurtured, the kinds of things

DR. Quevedo was talking about, in the institution. If you don't really nurture the relationship with the thought leaders in the medical center, to have them understand that you are really doing a responsible medical practice that is going to enrich patient care and focusing in on as much evidence basis as you can, that you are going to be fighting an uphill battle. You may have one or two key people, but with another eight or 10 prominent people backstabbing, it is going to be difficult to make a success of it. So I think that is one aspect. The other is funding, and it is very difficult within the hospital. In the hospital it is difficult to deliver the services because in terms of DRGs, how do you carve out, out of a surgeon's cell, getting massage or yoga? And that was an area of contention particularly at Columbia. And the other is just in terms of if you are going to accept managed care, how you actually can be financially viable, and that is a very difficult issue that I think if I get into that, we will be here all day. So I will just say that was a main issue, and that we are primarily fee-for-service at the moment, but trying to develop a relationship with insurance companies to have them recognize the value of what we are doing, and by the data that we are capable of accumulating to look at the cost- benefits. Not being a big fan of the managed care system, I will say, though, in their defense, they aren't a lot of cost analyses to show what works and what is cost-effective, and we have an ability at these centers, particularly the academic ones, to be able to begin tracking that for them and being in partnership with the insurance companies. But it was primarily underfunding, managed care, reimbursement difficulties, and particularly bad politics within relationships between the CAM centers and the institution.

DR. GORDON: Thank you for the answer. And since we will be coming back to reimbursement, maybe you can help us with what you are learning about fee-for-service and managed care and what some of the difficulties are, and then help shape our recommendations for that as well. Charlotte. SISTER KERR:

DR. Quevedo, when you gave your presentation, I heard several times belief matters, that people understood that there was more than sciences related to healing. And then you again said language and belief matters, and then you said belief matters. So I wonder specifically --

DR. QUEVEDO: Just believe it. [Laughter.] SISTER KERR: -- how is that essential to your work? And does or can this have implications for policy?

DR. QUEVEDO: Good question. Is it essential to my work, and how do I incorporate it, is that a fair restatement of the question? My own culture, my own experience, has led me to know many different experiences with healing. But I was one of these folks that loved science. I mean I loved Western science, and I think when I was less aware of my own spiritual development, I think a lot of what drew me to science was not so much what was known, but what was not known. In fact, I was attracted to the mystery of life, and the mysteries of nature. Now as I understood over time that there was a part of me that was much broader simply than a given empirical representation that the natural world would describe, I realized that this is also occurring for patients. Now when I was in medical school in my early years of training, this was largely represented as in the category of psycho-social factors, somehow outside the realm of the hard sciences, and not nearly so important as biochemistry, et cetera, et cetera. Yet, as every clinician knows, these factors are enormously important in the case of patients, and sometimes are more powerful than a given drug, et cetera, and determine behavior. What I have learned in my own explorations of this newer view of medicine, this newer vision that I call integrative medicine, is that there is a biology of belief, as Herb Bensen has called it, that we know from studies of the placebo response, et cetera, from much of the work that many members of the Commission have done in the area of mind-body medicine, that this is not only about culture and philosophy, but it is also about biology. So I would simply say to you that once I had incorporated that into my own thinking, my own belief system, I have taken quite seriously the act of being with patients and listening to them, practicing presence, as well as trying to work with their conceptions of reality and translate across cultures. And very often that is with people who are educated in America, et cetera, et cetera. We are still working across cultures.

DR. GORDON: Thank you. Wayne, and then Julia, and then we will close it down.

DR. JONAS: Well, Charlotte, as usual, you have stolen the most profound question. [Laughter.]

DR. JONAS: So I am going to have to backtrack to the more mundane issues. I think if anything comes out of this Commission, if we can get our money and our minds together, or perhaps more appropriately our health care and our heart, we will have succeeded, regardless of what else happens. I am specifically interested in how much activity CAM practices are actually going on in-patient, because this is an area that I haven't really seen touched very much, and is an avenue that perhaps has some rich potential. Could you comment a little bit on that? Are there practitioners in the CAM area making rounds, seeing patients in the hospital, making suggestions, working with physicians under those conditions?

DR. QUEVEDO: I can tell you what we are doing. The Center for Integrative Medicine at our particular hospital is now about 18 months old. The credentialing strategy, which was largely to set up an ad hoc credentialing committee that reports to the medical executive and also to the credentialing committee of the medical staff, we report quarterly to the medical-executive body, et cetera. That strategy has been largely seen as successful, as acceptable, and where there have been issues raised regarding process, we have had a structure in place to deliberate them. Out of that, an interesting thing happened. There were a couple of patients in the ICU who requested acupuncture. One was an Asian patient who had head trauma and who had sensorium changes, and the neurosurgeon and internist taking care of the patient did not want to use sedating drugs because they were watching neurologic signs, et cetera. The family of the patient requested that his headaches be treated with acupuncture. The internist and the neurosurgeon, because they knew of the center, asked for it as a consultation. Our agreement with the medical executive body had been that we would limit the scope of practice and our credentialing to the out-patient setting until we gained enough experience to make recommendations to go beyond that. So we declined the opportunity to provide acupuncture in the in-patient setting, and the ICU nurses and the nursing director were really disappointed. The chief of staff asked me to represent the case at the NAC meeting following that, and as I was getting ready to do it, the chairman of anesthesiology and critical care did it for me. She said that it was really a tragedy that we couldn't provide this, since we have gained all this experience in the out-patient setting. That led to a unanimous resolution by the chiefs of departments to create a credentialing strategy to bring selected therapies into the in-patient setting. At the same time the hospital was cited by the Joint Commission for having too narrow an approach to pain management, being excessively pharmacologic in orientation. So the anesthesiology chair and the surgery chair also came to us and said would we participate in designing a CAM strategy to be incorporated and make their JACO response look a little better. And so we did that, and that is targeted to start in January 2001, and we will be bringing massage therapy and acupuncture into an integrated pain management team that will be actually run by the department of anesthesia. The formula that we are using is that we are using the Center for Integrative Medicine as a proving ground to credential and evaluate potential practitioners for the in- patient setting, and then the CIM, the Center for Integrative Medicine, and the credentialing committee of our center will make recommendations to the credentials committee of the medical staff. Without having the groundwork, the credentials committee chairman basically said, you know, we wouldn't be able to do this, because they didn't want to deal with it, essentially. So that is what has happened here, and we are planning to start that in January. Up to this point, it has been a little bit of massage therapy and that is it, really, in the in-patient setting.

DR. MERRELL: We have credentialed both in-patient and out-patient chiropractic massage and acupuncture for CAM services, and then anyone who has a license essentially can do mind-body therapy, whether it is a Ph.D. or RN, NP, et cetera, and that already exists and actually our nursing program has developed, with the approval of the chairs of the department of surgery, a pre-op surgery program that provides patients with imaging hypnosis before Reikian therapy and touch during and after surgery, institution- wide. What is required in credentialing is that in order to have chiropractic acupuncture in the medical setting, the attending physician of the hospitalized patient has to request it, and actually the chair has to approve it, but the chairs have all said that they approve it if the attending asks for it. So they don't need to go to that second level. We are just beginning now to have chiropractic available in the spine center for low back pain and acupuncture beginning particularly for post-surgery patients. So we are just open five months, so we are just beginning to get into the in-patient settings, but the plan is to expand it and make it available to every department, and more than that, have each department have their own people so they don't keep calling us in to provide the services, but that they take ownership so it is integrated to their department. Not that it is some boutique or separate department that is occasionally providing services to the institution.a

DR. GORDON: I'm sorry, I am not sure I understood. You are providing all the services, or they have their own providers?

DR. MERRELL: No, at the moment, we are providing them, so we want them to provide their own, eventually. We are helping to work with them to actually -- if they want there to be a department of integrative medicine, eventually there will be, but not to provide services throughout all the hospitals, more to provide guidelines on credentialing, to try and coordinate things. But we really hope that each department, in and of itself, will hire the practitioners to do their own services, so that it is not one separate department, but each department takes ownership. Right now we are the only game in town, so practically we are doing it.

DR. GORDON: So you provided the credentialing system that has been accepted by the hospital, and then within that system, they would then hire their own people?

DR. MERRELL: Yes. Each department could hire its own people with the same credentialing guidelines. It is not just for us, it is for the whole institution.

DR. GORDON: Do you have any sense of the demand that might occur in this, or how many patients can actually request it, use it, or --

DR. MERRELL: Yes. The demand is huge in the surgical program, and in-patients that come in already have increased the patients using chiropractic and acupuncture, have already started asking for the services. It is only the fact that we don't have enough personnel to schlepp over to the hospital to do all these things has prevented us from doing more in-patient work, because the patients, now that they know this is available, they are beginning to request it.

DR. GORDON: Maybe one of your fellows could be an exploratory venture into a CAM hospital. Is there something like that?

DR. MERRELL: To the fellows, that will be a definite role for them.

DR. GORDON: Julia.

MS. SCOTT: Thank you. This is for

DR. Merrell. Earlier one of the Commissioners asked if these CAM services were available to the underserved, underinsured, and medically unserved, and you responded that these populations were served by two affiliated clinics. My question is, are the CAM services offered different than those at the academic center? And if so, what are the differences?

DR. MERRELL: No. I think this is a unique situation. I was trying to figure how you could make this applicable to the rest of the nation, but we are in a uniquely fortunate situation. Actually the department of family medicine is hooked up with the Institute of Urban Studies, and for 10 years has had a Sidney Hillman center that originally was private, now state-funded to provide care to the uninsured, underinsured Medicaid, and they have been routinely providing care and nutrition and nutritional therapies, Chinese medicine, acupuncture, mind-body therapies to patients with classes on yoga and massage, meditation, tai chi, and that has been for over a decade. There is also a clinic that is semi-private, but is actually affiliated with the hospital, that serves primarily Hispanic and African-American population. That has also for decades been providing those services. Again, it is a Title 28 facility, largely state-funded, providing all those services. So we are fortunate in that we couldn't afford financially to make a go of it just serving a high percentage of the population, but within the system we have it worked out so that that is already available. The formula of how you incorporate all that under one roof obviously requires a degree of subsidy in a center, unless it is a fairly bare-bones set-up.

MS. SCOTT: Thank you.

DR. GORDON: Thank you. Thank you all three very much for the richness of the presentations. We will take a five-minute break, and then we will have the next panel. [Recess.]

DR. GORDON: We are going to begin with the next panel now, so if the panelists can come forward, and the Commissioners can come sit. One of the things I want to say at this point is to very much thank the subcommittee that has worked on this program, and also our staff. This has been a labor of love. Part of the labor of love has been to orchestrate a program in which we see both specific examples of different kinds of integration and different kinds of CAM programs, and at the same time we are enabled to take a larger view. This is one of the larger-view panels. We have two people on the panel who represent managed care organizations, and a third, Lori Bielinski, who works with the Washington State Insurance Commissioner and has a major role in helping to design and implement plans of health care. So, in a sense, it is a kind of -- I don't know what you would call it, oversight supervisory regulation. What we are going to do is we are going to begin first with James Dillard, and then Anna Silberman, and then Lori Bielinski will be third. So, James Dillard.

DR. DILLARD: Thank you,

DR. Gordon. I am glad to be here to talk to you. I am an acupuncturist chiropractor and medical doctor. I have had a chance to do a lot of different things in the alternative medicine arena. In 1995 and '96, I was asked to consult with Oxford Health Plans based in Connecticut at that time, still is, basically doing business in the tri-state area of New York, New Jersey, and Connecticut, to help build a comprehensive CAM program inside the insurance company.

DR. Rasama That was the business director, I was the first medical director in October of 1996. We built a program, and I am sure many of you are familiar with the program. We credentialed almost 3000 providers and six provider types, and went live January 1 of 1997. It has been a model program in many ways, and pretty successful. Unfortunately, the company had some financial challenges at the end of 1997, their stock dropped precipitously, and so it has been an interesting but in some ways an incomplete experiment in building a CAM program inside a managed care organization, simply because we have had financial challenges since the beginning of 1998 until recently. Fortunately, the company has done a very remarkable financial turnaround and is one of the more solvent insurance companies, managed care companies, in the country right now, thanks to our CEO,

DR. Norman Payson. The reality is -- and you can ask me more questions about the program, if you like -- the reality is that a lot of managed care companies aren't doing so well financially. Ten years ago they were the darlings of Wall Street. Now, they are not considered to be great investments. A lot of them are having trouble making profits, difficulties with their projections, and I think it has changed the whole environment for building these kinds of programs inside managed care. It has become much more of a challenge. Our chief medical officer, Alan Muney, would want me to tell you that we really should not endorse or try to weave in things that don't have very strong evidence, because the reality is that we just can't pay for it right now. We have limited resources. We don't want to have things that represent duplicative services, that may have marginal outcomes. The idea of somebody seeing the acupuncturist and pulmonologist for their asthma at the same time, that are certainly additive costs. We don't have the kind of data we need to comprehensively dovetail these things. But the Oxford program is still a very interesting model. It is a three-tiered model consisting of standard benefits, an alternative medicine rider, and contracted network of providers, what we call affinity plans being referred to as now. But the question also comes down to, where are you going to spend the money. We just don't necessarily have the money to do everything for everybody as is necessarily wise or even effective. I think the Oxford program did represent access inside a large managed care company which was considered to be one of the silk-and-satin plans on the East Coast. It was middle class, upper middle class, upper class. We insure a lot of the big Madison Avenue fir

MS. It was part of the boutique quality of the plan, and continues to be a major part of its identity today. I can address some issues of integration, trying to create integration inside a managed care organization. We made some, I think, successful attempts at that. In some ways, we were not able to fully execute, even though our plan was pretty good, because of the financial challenges of 1998 and 1999. Some of those plans are still on the drawing board, and we may have the opportunity to carry some of those things through. There are a number of barriers to that integration. There is resistance on the part of the physicians, there is resistance on the part of the CAM practitioners, and also the patients tend to compartmentalize quite a bit, which has already been talked about. It also takes a lot of time to do the integration, and it is not easy to do, particularly in terms of the managed care plan. When we actually started this, we wanted to be able to share all our records between the CAM practitioners and the 14,000 primary care physicians at Oxford. We got a strong push-back in focus groups and from other patient groups, that they didn't want us to share those records. They didn't want us to tell their primary care physician that they were seeing the acupuncturist, and under law, they have the right to do that. The patient's record belongs to the patient. If a patient tells us we are not supposed to tell their internist that they are going to see a massage therapist or a nutrition counselor, we have no choice. We cannot create integration. We saw some rather strong push- back on that when we first created the program, which I think is another interesting point. Many of us have been talking about whether or not it is possible to fully integrate these things. So I would simply say that, overall, it is appropriate to create access to the therapies we consider to be safe, and embrace reimbursement, only for those therapies which have strong evidence base. Thank you.

DR. GORDON: Thank you very much. Anna Silberman.

MS. SILBERMAN: My preference is to present an example of access and delivery issues that have been solved by High Mark Blue Cross/Blue Shield in Pittsburgh, Pennsylvania. Yesterday, you heard the testimony of Rick Collins, our medical director for the Dean Ornish Program out in Nebraska, and Walter Czapliewicz, a patient from Pittsburgh. In 1997, High Mark made medical pair history by becoming the first insurance company in the country to both provide and pay for the Ornish program for any of our members who have any of our products absolutely free of charge, because what we learned is that if heart disease is just bypass with surgery, without also addressing the causes, then the problems tend to come back again. That is why bypass surgeries are often repeated within 10 years, and angioplasties within six months. So High Mark decided it would actually be ethically and financially irresponsible not to offer this alternative to bypass surgery. Our decision was easy for two reasons: Number one, it makes sense for the patient. As you heard, the Ornish program works, it is the right thing to do; and number two, it makes good financial sense. It pays for us to invest in proven alternative therapies to reduce utilization. The Ornish program has four components: moderate aerobic exercise; group social support; a low fat vegetarian diet, with supplements; and stress management, which includes meditation, yoga, progressive relaxation, and guided imagery. So you see this is truly health care and not just sick care. The program is delivered by a team of physicians, exercise physiologists, registered dieticians, yoga instructors, behavioral health clinicians, and other professionals, both alternative and conventional, all executed by the ninth largest health insurance company in the country. The team services patients for 10 hours a week, helping them to integrate better health practices and self management into their lives. We also help them develop meaningful relationships in a supportive and very loving environment. It is a very odd thing to see at the corporate headquarters of a large insurance company, but our senior management supported the Ornish program because of the science behind it. It can reverse heart disease, and it has. Our patients have 57 percent less angina; 50 percent less depression; cholesterol improved by an average of 22 points; and body fat by 10 percent. All of these biometric and psycho-social risk factor improvements are statistically significant. I believe you all have a chart in your books with even more dimensions. But most importantly, there has not been a single heart attack or death since 1977, when we implemented this program. There has been one bypass surgery, one stroke, and four angioplasties among these 400-plus very high risk patients. The point is these cardiac events are far below what would otherwise be expected with conventional treatment.

DR. GORDON: Excuse me. Let me interrupt for just a second. It is Tab J, Roman numeral V, Tab J. Roman numeral V, Tab J.

MS. SILBERMAN: So we would expect 77 percent of our patients with this type of risk profile to experience some type of adverse cardiac event. The Ornish program is completely safe, there is no risk, there is no downside. So this alternative is actually very conservative medicine at its best. The outcome data challenges the progressive nature of heart disease and the progressive expense histories for cardiac clai

MS. Our actuaries agree. They have calculated savings of $17,000 per patient, which translates into a little over $8 million in savings. The preliminary results of our matched control group study indicate a $297 per member, per month difference between our treatment and control groups. So we were able to draw on a lot more than good intentions here when we decided to start a new company to roll this out across the country. It is called Lifestyle Advantage, and the purpose of Lifestyle Advantage is to change the way or somehow influence the way heart disease is managed and financed. In our view, providers and payers must come together to do what is right and to do what is cost- effective. You need reimbursement for CAM services to become permanently ingrained in our health care system. It is one of the reasons we formed Lifestyle Advantage. With this union, our new company is well positioned to increase reimbursement and access by using the relationships that High Mark already has with other Blue Cross/Blue Shield plans. In fact, many have already chosen to reimburse for the Ornish program, and we have reimbursement codes that are now available to be used nationally. In summary, our program is less painful, less expensive, more effective in the long run. It is one of the things a health plan can do to be socially and financially responsible, and for High Mark it gives us a great opportunity to earn customer respect, trust and genuine patient satisfaction, build bridges between the alternative and conventional communities, and I will go into my recommendations in a few minutes. But thank you so much for representing our core values.

DR. GORDON: Thank you very much. Lori Bielinski.

MS. BIELINSKI: Good morning,

DR. Gordon and members of the Commission. It is my honor to address you today regarding access and delivery of complementary and alternative medicine services. I will start with some of the background about how the Washington State Every Category of Provider law is being implemented since there are great misunderstandings. Although the law has taken great criticisms, it is important to note that it is one of the few sections of Washington's 1993 Health Care Reform Act, part of the act that was not repealed. It was the most controversial and most popular reform, and ultimately was let stand by the U.S. Supreme Court. The law has taken into account the attempt of managed health care to save money, as well as giving patients some access to choice and involvement in their health care options. This is not in any way a provider law, nor is it a mandated benefit law. It allows consumers a choice of the provider who will treat the condition in which they are seeking care. There are currently several different coverage models of CAM services used in Washington State. Neither the OIC nor any of its collaborative work groups have recommended a right way of including these benefits. Each approach has advantages and limitations for various constituencies. The first is the dollar cap method, which is a straightforward benefit that generally applies a maximum dollar amount given per coverage year for a set range of CAM services. Acupuncture, massage therapy, and naturopathic medicine are the most commonly included services under this model. CAM benefits may require referral from a primary care provider and patients must pay necessary co-pays and deductibles. When the limit has been placed on more than one profession or all of CAM services, the Office of the Insurance Commissioner would deny approval of that benefit limit. The condition-based model bases benefits on allowances related to specific clinical diagnoses or conditions, such as acupuncture for chemical dependency, or naturopathic care for migraine headaches. The covered benefit may require specific clinical regimens to have been followed prior to the referral of CAM services. An example is requiring a physical therapy service prior to authorizing massage therapy services. The condition-based approach is usually requiring a PCP referral and co-payments and deductibles apply. The gatekeeper method is frequently employed under managed care strategies. A unique difference with this model is that in some cases the naturopathic physician is eligible to be a primary care provider. Patients seeking CAM services to be covered under their insurance benefits need to have a referral from their PCP, whether that is an MD, DO or ARNP. The benefits are subject to medical necessity requirements and established by the insurer that may be determined by the at-risk PCP group as well. The open access model is built on strong care coordination and quality infrastructure, allowing integration of CAM and conventional practitioners and their services. Enrollees are allowed access to network providers of all categories without a PCP referral. In fact, there is no PCP or gatekeeper required. The self-referral method allows patients to directly access all providers and preventive care services and usually a separate rider. Although the self-referral approach method does not usually require a PCP referral, benefits are subject to medical necessity determinations. Frequently the self-referral approach may be implemented in conjunction with a preventive care benefit. Preventive care benefits are not usually part of the policy, but can be negotiated by the purchaser. The discount networks are where some insurers have begun to negotiate discounts with CAM providers through a contract of network for their policyholders, in exchange for being listed in the carriers' approved provider guide. These carriers do not provide reimbursement for the enrollees' expenses and costs are paid directly by the patient. This is not in compliance with our statute and rules related to the other category of provider law, since the patient doesn't actually engage their benefits when seeking care from CAM providers. Carriers have the right to set coverage limits, including services of CAM providers and the OIC rules state that these limits may not be unreasonable and may not be set by provider type but can be set by covered services. The carriers can't exclude a particular category of provider altogether, nor can it cover certain provider types only by a separately priced optional benefit. Reasonable limit has yet to be defined, and the filed limits by each of the carriers is something currently under review. A data call related to the criteria used by insurers to establish limits for health care services is currently under way by our agency. After a preliminary review of this data, I can tell you there is no established pattern of how these limits are set. In text, I have provided you some of the preliminary results, but consequently, when carriers contract with outside entities to provide these panels, there seems to be a disconnect to the very concept of integrative medicine. To close, I will reference a chart I submitted in advance, outlining the reported coverage that insurers in Washington State indicate is available to their enrollees. I would like to point out that there is conflicting information from many of the carriers regarding what they file as benefits, what the cost of the benefit is to them of their purchaser, and what they report in policy increase as to how they manage the benefit. I will end there. Panel Discussion

DR. GORDON: Okay. Well, thank you. We will come back to you. All right, we have questions. We will start with George. Go ahead. And then George.


DR. Dillard, first of all, within the CAM managed care industry, you have certainly earned a position of respect throughout the country, and we really appreciate you being here today, and what you have done at Oxford has been significant. You have talked about access to some extent. Can you share with us the degree of success Oxford has had with the supplemental benefit programs for chiropractic or acupuncture, I believe, as well as naturopathy, and perhaps the perception you have of employers' willingness to pay for the benefits, but then potentially the difference between member accessing care under those programs versus perhaps through other systems you have, where members can access CAM benefits within Oxford?

DR. DILLARD: Sure. There is a lot in that question. Our program is the three-tiered program, just to remind you. We have some standard benefits. We have an alternative medicine rider, which is available at a group level for a slight increase in premiums per year. And then we have a contracted network of providers that is available at a set rate, the Oxford rate. We already had a small benefit for chiropractic when we were building the program. We went to a standard benefit for chiropractic for all three states we were doing business in at that time, and we treated the chiropractors just like other medical specialists. They would require a referral by a primary care physician, and the primary care physicians didn't want to manage that benefit. They said we would be more comfortable if you manage it. We will make the referral, you manage it, and so we gave them eight visits before they had to send us a care plan to allow the majority of the care to pass under the utilization management threshold. So that is in all three states standard benefit for chiropractic. There is also a mandated benefit in Connecticut for naturopathic services which we treat exactly the same way as we do chiropractors. Acupuncture was put into a rider which was sold to about 60 large groups, medium to large groups, and was delivered in the same way and managed the same way as the chiropractic was in terms of an eight-visit limit. Our recent surveys have shown that the most popular parts of the program have been chiropractic, nutrition, massage and acupuncture, probably in that order. I did supply you with a more recent survey, one that was done in 1999, and two in 2000, which will give you some of that raw material. The question becomes what is access? Is access something that is paid for? Is it just having a practitioner available? We felt we were creating access by having a vetted network of practitioners whom we have looked at pretty closely, and we felt that that represented a value added to the member. It is access, it is not reimbursement. Those are not the same. Of course, they are related. So I think again the highest area of utilization was undoubtedly chiropractic. I think massage and nutrition were somewhere after that, but those were in the contracted rate program, and that is all in the survey. I don't know if I answered your question fully. Was there something I --

DR. DeVRIES: Well, perhaps have you seen in your survey work that in terms of patient access of care, have you seen a difference between when services are covered as a benefit, versus your discount access programs? Are more members utilizing CAM professions under benefit programs than under simply discount programs?

DR. DILLARD: Yes. That is a good question. We do have a discounted network program for chiropractic, which means they don't have to necessarily get a primary care physician referral. They can go to a chiropractor and simply pay the Oxford rate. We think that the vast majority of utilization has been through the benefit with the primary care physician referral. We have not been able to fully capture that data. We were entering into a comprehensive research contract with

DR. Eisenberg's group at Harvard in 1997, when we had the financial challenges that I described, and we had to cancel that contract, unfortunately. I think we could have gotten a lot of this kind of interesting data. I am not sure about all those, George. I mean there are some details there that I don't have.

DR. DeVRIES: And one other follow-up. Just the difference in access between when services are direct access, when there is direct access to the complementary health care provider versus going through physician referral, have you seen any differences related to access there?

DR. DILLARD: The product of alternative medicine rider was a direct access program. It allowed direct access without the primary care physician involved. Again, we have not been fully able to study that, but we think that that was a fairly popular product, that people liked that. There are always difficulties with gatekeepers in conventional utilization. I think a lot of people are uncomfortable with having to go to their gatekeeper to go see an obstetrician-gynecologist. It is a common complaint. I think there is a strong possibility we could look at more non-gatekeeper products. But again, there is a challenge in knowing how to price them.

DR. GORDON: George.

DR. BERNIER: I have a question for Anna Silberman. Those are really impressive numbers, the $17,000 per participant that you saved, and the win/win situation. Are you looking forward to using other CAM modalities in such a terrific way?

MS. SILBERMAN: I have to say that George was one of the original members of our board of directors before he moved on to Texas, so I am surprised to see him here after eight or 10 years. What we have is a delivery system called Health Place. We have 17 centers that deliver CAM programs on a daily basis to about 40,000 people a month. Some of those services include all of the things that we talked about today. I think our most popular service is nutrition counseling, both in a preventive way and for people who have chronic conditions. One of the programs that I am especially proud of is called Hope, and that is a program for osteoporosis. We have two arms of that, one for people who already have the diagnosis, and a preventive program for those who do not. It centers around nutrition, strength training, all kinds of health promotion modalities. This is really unusual, I don't think it would be considered CAM, but our building engineers actually go into the homes of our members who are at risk for osteoporosis and clean up any hazards that are there, and install grab bars and so on. But the bottom line is, is the results of the program, and since we have implemented that about three and a half years ago, we haven't had a single fall or fracture. So it is nice to do these kinds of interventions, but when it comes back as a cost savings, it really helps it continue on and grow.

DR. GORDON: Thank you. Toni.

DR. LOW DOG: Well, that is great. That was really my fear. I have questions for everybody, but since I can only have one, I will ask Lori. When we were up in Seattle, it was staggering to see what has been done up there and, of course, we had the benefit of coming in after all this work had sort of been done. Now that you have got some of it behind you, do you have any pearls of wisdom for us and recommendations, or things that you would have done differently, or better, or problems, any advice for us that we can take after reviewing all this material and spending that weekend in Seattle?

MS. BIELINSKI: I think the significant thing from my perspective is that I always get confused when I have to explain the law to somebody. It is baffling to me how many times I explain it to the same person and they still think it is a mandated benefit law, and that it doesn't honor managed care. So the one thing I would say is keep reading the explanations I have given you because even the only cost-benefit analysis that I have seen on CAM services from Milliman Robertson, which is one of the more significant actuarial firms, still declared our law a mandated benefit law, which is the only reason it got through the Ninth Circuit Court of Appeals, is because it is not a mandated benefit. So in each state where there are various laws, pay very close attention to that. The other side of it is where the independent networks have a relationship with the Office of the Insurance Commissioner and the carriers that we regulate. The Office of the Insurance Commissioner in some states is elected, some it is appointed, and it is about a 50-50 split. For our agency, we are elected, and so we have a very consumer advocacy role for the consumers, as well as how we work with all the entities that we regulate. We don't regulate the networks, the primary care organizations, the CAM services networks, and when there are relationships established between the independent networks that we don't regulate and the carriers that we do regulate, sometimes there are problems with how the independent contracted entity, for lack of a better term, is going to treat the providers that fall under various regulations that we do have. And significantly, right now in our state, there is one contracted network for CAM services that has obtained the contract with the largest carrier in the state. They haven't completed that relationship, yet they are contacting and discussing and contracting with providers. It has consumed nine weeks of my time, just on that one issue. It is a huge problem. The contracts for the providers are regulated by our agency, yet we haven't seen it because the carrier and the network haven't finished their relationship. The carrier would have to file that contract with our agency. So they are disbursing a contract that has not been approved by the agency that they use in a different state, with different laws, and the providers are -- I have 2000 complaint letters in my office right now that I have to respond to. So I would say, to summarize my point, have the carriers and the networks complete their relationship first. Think about what you are doing to the providers in the context of continuity of care. Every single patient that these providers are seeing is going to be affected if their provider is included in the new network or cut out. This particular network will cut the chiropractors and massage therapists current network in half, at least. So patients that are seen by half of those networks are going to lose their doctors. Open enrollment for the largest self-insured entity just closed November 30th, so you can imagine the ripple effect of what is going to happen.

DR. GORDON: Veronica?

DR. GUTIERREZ: Thank you. My question was on the same subject, so unless you would like to expand on any time remaining on the discussion, I am fine, thank you.

MS. BIELINSKI: I think that is enough said.

DR. GORDON: Wayne.

DR. JONAS: I had a question for

MS. Silberman. In answering your first question, why and how did you select the Ornish program, you described the data and that type of stuff, which is great. I am wondering, were there any individuals who were in the management hierarchy of Blue Cross that have had personal experience with the Ornish program?

MS. SILBERMAN: In this case, no. In some of our other sites across the country, there are 12 of them, that is true. In the case of High Mark Blue Cross/Blue Shield, no, there hadn't been anybody at that point in time. Once we implemented the program, some of our executives took advantage of it, for both themselves and their family members. It was simply a matter of, you know, I heard

DR. Ornish speak at a conference, and to me it made good sense, and they received it very well.

DR. JONAS: So you brought it to them, then?

MS. SILBERMAN: Yes, I did. There were a number of skeptics, of course, internally who -- you know, they called me Anna Alternative and all kinds of things like that, so we had our share of those folks who were asking me if my VW bus was outside. There were a lot of skeptics who are the very same people who are now attending our program.

DR. GORDON: Tom, and then George.

MR. CHAPPELL: James, I am just wondering about the economic sustainability of your approach to this, and whether you envision this becoming a highly profitable and sustainable approach for your company.

DR. DILLARD: It is a good question. I don't think that Oxford approached this from the viewpoint --

MR. CHAPPELL: I heard you say that, but I am wondering whether you envision -- is this ready for commercial profits, as well as social profits at this point?

DR. DILLARD: I don't know specifically what our ROI would be. It has not been fully calculated. I wish I could give you that information. The perception has been that this has been a pretty low cost program to roll out inside a managed care company. The fact is that during 1997, the company grew from 1.4 million members to over 2 million, almost 2.2 million members, with the alternative medicine program as one of the major pieces of its marketing and public relations. It was considered to be a very successful program for this reason. How to interpret that and place that into profitability, the company was doing very, very well at that point. The 52-week was 89, and after we had a rather bad projected earnings in October 27th of 1997, it went down to a 52-week low of six, which had actually nothing to do with the alternative medicine program. I really want to make that clear because a lot of people think about the Oxford program, they go, hmmm, interesting program, alternative medicine, tanked the company. Not true. I think we still see it, not necessarily directly in the revenue stream, but something that lends a lot to the brand, and is considered to be still by our operating officers as being a major part of the Oxford brand.

DR. GORDON: George, and then Joe.

DR. DeVRIES: Lori, could you help the Commission maybe understand how the Department of Insurance in Washington looks at -- and I am thinking of your regulatory requirements related to access to CAM providers, and how you look at that to comparison to medical providers, whether it be access ratios, providers to total number of patients, or members, or access in terms of geographic distance, how you look at access?

MS. BIELINSKI: Sure. Let me start first with the carriers set their own network adequacy requirements based on their enrollment and the geographic location of the majority of their enrollment. They have to file that standard with our agency. We don't have a formula and statute or a rule, but I understand that it is probable, and I am sure there is some drafting currently going on, we are in a transition situation with a new commissioner, so some of this will be delayed. But there have been significant complaints filed by consumers about lack of access, and the one thing I will say in Washington is CAM is not really differentiated with conventional medicine any more. It is just do you have access to your providers, are they primary or specialty, and specialty includes cardiologists and massage therapists. So that is where we come from in our mindset. The network adequacy requirements are generally one per thousand. I did just a review of this in terms of how carriers are setting limits on specifically CAM services, but all services, and the survey included all types of providers. So it is one per thousand members in a geographic location, usually broken down by zip code. The ratio or the requirement for driving distance usually is eight miles in a metropolitan area, 15 miles in a suburban area, and 60 miles in a rural area, which in some of our rural communities, it sounds like a long way, but it is not. So that is generally the amount. The part where it gets to be confusing is when they set an arbitrary limit. I heard James Dillard mention eight visits. That, in our agency, is considered arbitrary, so we are undergoing a review right now of again CAM and conventional services based on primary versus specialty, and how you set any limit, or what criteria, standards, guidelines are you using, and cite the most significant reference for all of it. What conditions are you limiting? How are you limiting it, and why? Why do the chiropractors want 22 visits a year to treat X number of conditions, versus the carriers wanting to pay for eight a year? What makes one less arbitrary than the other is where we are trying to get to. Summarily I can tell you in a brief review of this that I did on the plane, there is no pattern, and it is very arbitrary, and I am not sure what anybody is going to do about it. So if I were to leave you with a second recommendation, I would say find out what the criteria, what is the most common guideline used for any medical necessity definition to setting a limit on anything? Because otherwise the carriers could be allowed to sell what is considered in our world an illusory benefit. Six visits to a chiropractor a year doesn't treat most conditions I am aware of, and thank goodness for my medical background.

DR. DILLARD: If I can just clarify the one point. The eight-visit limit is not the visit limits. That is the point at which we ask for any information from the provider. That is when utilization starts, and that was based upon numbers that came from the Canadian report published by Pramanga, and I can give you the citations I am referring to.

MS. BIELINSKI: I wasn't trying to pick a fight. [Laughter.]

DR. GORDON: Wayne.

DR. JONAS: It is a related question, actually. I wanted to ask

DR. Dillard a little bit about how you establish the benefit package which you have sort of begun to answer, but ask you about the appeals process and whether you have had problems with "overutilization" and, if so, how do you deal with it, what kind of mechanisms are in place to address the appeals process?

DR. DILLARD: Well, that is a huge topic. The benefits that we decided to go with -- first of all, we took six provider types from a survey, those were the ones that our members were already using, they were the most popular provider types, not rocket science. We went with mandated benefits. We knew that there was going to be a mandated benefit coming down, and instead of New York, we decided to be proactively involved with that. We actually had some input into the writing of that bill. Proactively, before that bill came out with benefits that were fully in compliance with the Insurance Equality Act, it was signed by George Petaki. In terms of the appeal process, this is all a peer-based appeals process. I didn't know any other way to do this. The programs were structured using peer advisory boards, and the appeals process was by using practicing acupuncturists and chiropractors and naturopaths in the community, to look at this care and say what is reasonable, what is falling outside of reasonable standards of care, looking at documentation, is the patient getting any better. We used really mechanisms with very similar conventional utilization.

DR. FINS: These were external reviews, though?

DR. DILLARD: No, they were internal.

DR. FINS: They were internal.

DR. DILLARD: Yes. We hired expertise from the community.

DR. FINS: So you have a conflict of interest, presumably? The people who are reviewing are on the Oxford payroll in some way or another?

DR. DILLARD: That is correct.

DR. FINS: Has that been satisfactory to your membership, as far as the appeal process?

DR. DILLARD: Our statistics tend to indicate that the majority of the network is pretty happy with what we do. We are considered to be the most generous payer in the Mid- Atlantic, by the way, and I think they haven't had too much of a problem. We have maybe 5 percent of the network, maybe 10 percent, that we consider to be somewhat of a problem. We are doing the provider profiling on that right now, and we will be looking much more closely at those practitioners to see the people who are trying to go up to 48 visits for a year, 52, 76, and look at those providers more specifically. But it has all been based upon peer review.

DR. GORDON: Any other questions before we close this panel?

MR. CHAPPELL: I think I have one more financial question. Do you have any sense of the relationship of income from CAM services versus all other services is?

DR. DILLARD: The income from our CAM program specifically?

MR. CHAPPELL: Yes. I haven't quite asked it the way I wanted to. Can you tell me what share of reimbursement is going for CAM services versus non-CAM services?

DR. DILLARD: I know what our costs per member per month would be, and they are fairly in line with standard numbers that you are going to hear on the Atlantic Coast. Let me make one thing clear. We did not raise our rates because we built this program. There was no cost that was passed on directly.

MR. CHAPPELL: Yes, I read that, James. Let me just repeat the question. Maybe I am not asking it right. What share of your reimbursement is going to CAM practitioners versus non-CAM practitioners?

DR. DILLARD: The percentages, I don't know off the top of my head. I could probably get that data for you.

MR. CHAPPELL: It would be very helpful because that is such a valued model. I mean is it less than 5 percent, is it --

DR. DILLARD: I would estimate that it is less than 5 percent. We have the big ticket items that all of the managed care companies have, the maternity care, the typical things that you see.

MR. CHAPPELL: I am trying to get a feel for how big a question we are asking for here, if we want to integrate reimbursement in existing management.

DR. DILLARD: Oh, yes, it is a critical issue. I can share with you what our PMPMs, and I can try to get some ratios with our conventional costs, if that would be helpful.

MR. CHAPPELL: That really would be great.


MR. CHAPPELL: Thank you.

DR. GORDON: I want to thank you all. One of the things I am realizing as I am sitting here is the wonderful collegial spirit that we feel with the three of you, and as well as with other presenters, and in line with Tom's request, I am wondering if all of you would help us even more with the next stage, by telling us what is working and what is not with what you are doing, because you all have exemplary progra

MS. So, with the Insurance Commissioner's Office, Lori, should this be a model standard? And if so, why? And if not, where should it improved? And similarly with each of you. I think that will be a long way to helping us as we make our decisions later on. Thank you very much. We will take five minutes, and only five, and then we will come back.

DR. GORDON: This panel, which we welcome now, is somewhat different from the other panels in that what we have been talking about earlier in bringing in some of those who have developed innovative services is integration, and we asked these three presenters to come to talk with us about models that are really fundamentally based on other systems of health care, other healing traditions other than Western medicine, although they may be studied or examined or understood in Western medical terms as well. So I am very happy to invite the three of you to come to present to us. Our first presenter will be

DR. Robert Schneider.

DR. SCHNEIDER: Thank you,

MR. Chairman, and members of the Commission. I think everyone here is aware of the recent survey in JAMA which reported that 40 percent of the American population, or nearly 100 million people, not only use CAM services, but in addition, and not necessarily the same people, suffer from one or more chronic disorders. This is despite this country having the most advanced health care system in the world. Therefore, it is clear, since half of our people have chronic diseases, that a new, more effective approach or complement to our conventional health care system is needed. Ayurveda, the topic of my discussion this morning, is part of a larger, more complete system of natural medicine derived from the ancient Veda tradition of India. This is called Vedic medicine, or the more recent restoration of this system, including the range of diagnostic and therapeutic approaches has been called Maharishi Vedic medicine which includes 40 approaches for dealing with influences of health, from levels of mind, physiology, behavior, the near environment, the distant environment, and even the public environment or public health perspectives. Over the past 30 years, there have been about 600 published scientific studies on the effectiveness of Vedic medicine approaches for the prevention and treatment of disease. These have been conducted at more than 100 independent institutions in more than 30 countries around the world. These include a series of randomized control trials conducted by our group and others sponsored by the National Institutes of Health on the effects of Vedic medicine approaches on prevention and treatment of cardiovascular disease. Reprints of these studies and review of literature is included in your Section K of your notebook, and in the reprints handed out this morning. But briefly, the clinical syndromes that have shown to be most responsive by control of clinic research to these various approaches of Vedic medicine, which include meditation, herbal approaches, diet, purification therapies, behavioral approaches, even the influences of architecture in an environment, include first cardiovascular disease, its risk factors, hypertension, smoking, psycho-social stress, high levels of oxidized lipids, cardiovascular morbidity, cardiovascular mortality, and related health costs. The second area, which has shown considerable effects are psychological disorders, depression, anxiety, and related behavioral disorders, such as substance abuse. There is preliminary evidence on cancer prevention and treatment in terms of quality of life improvements, as well as potentially on mortality rates. Chronic pain has been very responsive. Age- related disorders in mood, physical function, cognitive function, and quality of life have been responsive in a range of primary care disorders, or disorders commonly seen in primary care, such as insomnia, digestive disorders, chronic fatigue, and women's reproductive disorders, menstrual and menopausal sympto

MS. Second, in terms of cost effectiveness, several studies, which are reviewed in your handout and in your reprints, have reported 50 to 80 percent reductions in health care utilization and related health care costs, with the approach of transcendental meditation, part of Vedic medicine, and other Vedic medicine approaches. This has been true for both in-patient and out-patient utilization. Patient satisfaction is reflected in relatively high compliance rates with these modalities which in published reports have ranged from 80 to 97 percent regularity with these recommendations, which contrasts with modern recommendations, with compliance with modern pharmacotherapy, which is 33 to 50 percent, at least for anti-hypertensive regimens. So roughly twice as great. Based on these data, we have three main policy recommendations for this commission. One, regarding access, it is largely, although not exclusively, based on reimbursement policies. Therefore, we recommend that this Commission further recommend that natural medicine services, in this case Vedic medicine services that are shown to be effective and cost-effective in published, peer-reviewed scientific research, be reimbursed by third-party payers, including government payers, such as Medicare and Medicaid, and even recommendations for private reimbursers. Second, regarding delivery of services, this is largely determined by availability of qualified practitioners and their legal ability to practice in their respective area. In this domain, we recommend a two-stage process related to practice by qualified practitioners, to be phased in over a five-year period. First, that certified practitioners be allowed to practice in their areas, following the Minnesota model currently. Certified practitioners will be those who have successfully completed an approved course of study at a recognized and accredited institution of higher learning, and second, who are certified by national professional award in their field. Second, we recommend that over time states adopt a licensure procedure for natural medicine practitioners, including Vedic medicine practitioners, and licensure would be dependent on certification and completion of other state licensing requirements, such as an exam or experience requirements. Thirdly, in terms of delivery of services, this largely dependent on a continued stream or training of qualified practitioners. Therefore, in the area of education, we recommend that the Commission further recommend to the federal government the granting of grants, the provision of grants by the government, not for research as NCAM does, but in this case, grants to educational institutions of higher learning for the training of natural medicine practitioners, in particular, Vedic medicine practitioners. These institutions would be recognized in their field and also accredited by standard accrediting associations. In further consideration of delivery, whether it be within the exclusive framework on integrated with conventional health care delivery systems, my colleagues and I actually recommend both approaches. For example, there is now a series of maharishi Vedic medical centers being constructed in each Congressional district in this country, several of which are already up and running, which are examples of focus, providing natural medicine services within the community, and also within integrated health care services. In conclusion, Vedic medicine, including Ayurveda, but not limited to Ayurveda, much expanded beyond aruyveda, has been shown by extensive scientific research to be clinically effective and cost-effective.

DR. GORDON: I think we will come back and we will have some very specific questions about the inclusion of that provision of services. Thank you. Sorry to cut you off, but we have gone well over time.

DR. SCHNEIDER: Thank you.

DR. GORDON: Next will be

DR. Tori Hudson.

DR. HUDSON: Thank you,

DR. Gordon. Thank you for the invitation and the opportunity to be here today, and I really appreciate you including the voice of naturopathic physicians and attention to women's health, in particular. I usually start my lectures and presentations with a joke, but it cost me too much time. So I am open to solicitation later. Essentially, naturopathic physicians are licensed primary care family physicians with a specialty in natural medicine. We utilize nutrition and lifestyle counseling. We prescribe nutritional supplements, plant extracts, and other natural therapeutic substances and techniques, as well as selected pharmaceuticals. The seven principles of naturopathic medicine and the two additional integrative principles, as I discussed in my written testimony, could actually serve as the cornerstone of a new medical model, one that many of us are calling integrative medicine. But we must be careful, I think, to define integrative medicine, because if we do it right, it actually has a potential to fundamentally transform the quality of health care, the accessibility of health care, the cost of health care, and therefore the health and quality of life of our communities. My vision of integrative medicine is basically a cadre of health care disciplines and practitioners, each with their own scope of practice, each with their own tools of their trade, but also each with a common understanding, a common respect, and a shared commitment to coordinate care, cross-refer, and co-manage patients. The federal government could go a long way towards providing a framework in which all of this can take place. The framework, however, must impact the psychological, the cultural, the political, financial and logistical limitations and biases that currently exist. As it is now, the conventional model has monopolized and dominated medical education, medical research, medical reimbursement, and medical practice in this country, and remarkably, there are other medical approaches that are most often safer, often less expensive, and usually effective, but not always, in handling about 90 percent acute and chronic health care proble

MS. In women's health, an integrative medical framework from the top to the bottom of the system could actually bring us reliable treatments for very little understood and very poorly treated conditions, such as interstitial cystitis and vulvodinia, and fibromyalgia. It could bring attention to the extensive scientific data on the prevention of breast cancer with soy and fiber and fish oils and green tea, or the proven successful alternative treatments for cervical dysplasias. It could study outcomes of breast cancer patients who receive both conventional and alternative treatments. Much more common is the issue of menopause. By the year 2015, 50 percent of the U.S. female population will be menopausal. I will let you pause there, just to contemplate that. [Laughter.]

DR. HUDSON: What conventional medicine dominantly has to offer those women is that all women should take a prescription, hormone replacement therapy, that might lower their risk of heart disease, while at the same time definitively increase their risk of breast cancer. Why routinely use a drug that poses an increased risk of one disease to all, while decreasing the risk of another to only some? An integrative model would better identify individual risk factors for individual patients, not a one- size-fits-all approach, but individual assessment with an individualized treatment approach. Imagine intentional, structural, collegial, coordinated health care clinics and hospitals and research centers across the country, with MD, DC, DO, Ph.D., LAC, LMT, Ph.D., and all other allied practitioners working together to provide the best that each has to offer in the co-management of issues like osteoporosis and heart disease and breast cancer. But also a very common, every-day women's problem such as PMS and fibrocystic breasts, pelvic infections, menopause, endometriosis, and uterine fibroids. To me, integrative medicine is about maximizing the strengths of each discipline, while minimizing the weaknesses of each, so that we can have the best possible outcome for the patient. Women want their practitioners to work together. This can be seen in survey after survey. Women are hungry for education about their options. They are hungry for respect of their choices by their health care practitioners, and they are hungry for communication and coordination between their practitioners. Women, I would assert, are not only seeking this kind of coordinated, integrative health care, but the female patient, in my opinion, is actually making it happen, especially in the menopausal woman. Eighty to 90 percent of menopausal women who are prescribed hormone replacement therapy discontinue their hormone replacement therapy within the first year of use, and they seek alternatives, in many cases, and others receive no treatment at all, but they are especially engaging in a fairly complicated educational process of deciding when to use HRT, when to use botanicals, when to use supplements, and when to use a combination of those things. My experience in Portland, Oregon is one of having a women's integrative clinic with ND, MD, DC, acupuncturists, massage therapists and counselor working together, referring back and forth, discussing the co- management of shared patients. In my community we have a naturopathic medical school, a conventional medical school, a chiropractic college, an acupuncture college, two massage schools, and three schools of nursing. We have many examples in integration: costs or discipline preceptorships; and individual physician offices. We have referrals amongst all disciplines. We have joint research studies between the conventional medical school and the naturopathic medical school. We have integrative medical meetings, and continuing medical education into several integrative clinics, shared adjunctive faculty appointments, residency exchanges, and an integrative medicine residency. It appears obvious that the time has come for this concept of a team approach to health and well being, rather a multi-disciplined, truly integrative, safe, effective, affordable system of health care that respects the choices of individuals, the wisdom of many minds, and the spectrum of all that nature and humans have to offer. Thank you.

DR. GORDON: Thank you very much, Tori. Next is Robert Duggan. Bob, good morning.

MR. DUGGAN: Thank you. I am honored to be here and have a moment to speak with you. You have a written paper. I am going to make a few comments off of that. First of all, I would like to say that I have been practicing acupuncture for 30 years. I am the president of a school with 220 graduate students. We have 700 graduates across the country. Eighty-four percent of our graduates 10 years later are earning good incomes and higher than the national average for acupuncturists, and among our graduates, not a single graduate has ever defaulted on a federal student loan. I say that by way of credential. I am not here speaking on behalf of the acupuncture profession, but rather on behalf of some issues that confront acupuncturists, acupuncture practitioners and acupuncture schools. The first critical issue is that our students are trained not only in the modality of acupuncture, the skill of acupuncture, but in the art of healing. I think there is a conversation to be had that all of CAM and perhaps all of medicine in the country at the moment, is divided between modalities looked at in a reductionist mode, and the context of that modality within the art of healing or culture of healing. We have done studies that indicate patients keep looking for that art of healing, and then their satisfaction rate increases, and I can give you the reference to that. Your questions to me were about integration of acupuncture in mainstream and complementary medicine, integration of acupuncture with herbs, with the other parts of Oriental medicine, and the simple position that we have taken at the institute in Columbia, Maryland for 25 years is great diversity. Our graduates practice in an enormous range of situations, in hospitals, in private practice, and there should be just a fostering of enormous diversity. It takes 10 years to be a good acupuncturist. You can learn various skills, but that is one of the major things, and we have had a clear policy through those years of avoiding turf battles and been very conscious of that. One of the major -- and I suppose these are some of the policy implications that come out of our work over these years -- is when the conversation is who is the primary care provider, the patient is the primary care provider. The patient is the primary care provider. We will only shift the cost, quality, access dilemma in American health care when we understand that by making the patient the primary health care provider, we will move 70 percent of the visits out of the sick care system into a wellness culture. We know that is critical to the success of our acupuncturists. We know that the ones who see themselves as educators of the empowerment of the patient do better than those that are simply delivering a modality. I think we need to consider the economics. My graduates, our graduates, are being socialized into a reimbursement model that favors the modality over the healing art of the individual patient. We have one program we do with a corporation where the practitioner guarantees free treatment after a certain point if the patient hasn't taken on their own quality of care. Some other specifics that you might recommend, that all schools of medicine, complementary or mainstream, foster relationship-centered care, built on the recommendations for mainstream medical schools, and take that into all the complementary schools. Second, that there be a separate agency established to deal with the issue of the quality of herbs. We are well aware in traditional Chinese medicine of those issues, and the usual way of looking at it, which is not the same economics, not the same philosophy, that there be a separate and distinct agency. An issue that has come up locally in Maryland is in using some of the tobacco settlement money to encourage the use of the lands now devoted to tobacco growing for the growing of herbal products, high quality herbal products, and organic foods. There is a bill in Congress at the moment on the student loan repayment program to induce practitioners of complementary care to work in a city and areas of economic need. I think that is a bill that should be fostered, and anything that pushes the CAM providers in the direction of doing pro bono work should be supported in the community. I think CAM and wellness education from the first grade onward is an important outcome. I spend most of my clinical day educating people into simple realities that they should have learned in the grade school, and I think that is a background. The present licensing systems in most states for acupuncture forces the schools to devote all their time to technique and specific knowledge-based, rather than relationship-based educational-based learning. I think there is a policy that should move some of the research that is being done so that the research outcomes translate across into clinical practice. It is one thing to see the research outcomes. I rarely, in my clinical practice, experience that those research things are known in the local physician's office or the other CAM providers. I think that research on quality of life outcomes, rather than on mechanisms, should be fostered. There is an enormous expenditure trying to understand the mechanism of acupuncture or of an herb, and we know very little about the overall quality of life outcome. We have for 25 years at the institute refused to do clinical studies because we knew that patients were asking the question, my asthma has become my teacher. It is not that my asthma goes away, my symptom has become my teacher. So we ask the wrong question in research. There are other policy things that I have put in the papers. I would leave it there, and I am happy to take your questions. Panel Discussion

DR. GORDON: Great. Thank you. Thank you all three. There are obviously a tremendous range of issues on which each of the speakers can comment. I would like for us to focus pretty intensively on delivery of services in our questions. We can always ask them other questions afterwards, or indeed ask them to come back and sit on other panels. So if we could begin, please.

DR. TIAN: I have a question for Professor Duggan. I admire your work and your institution has done a lot in developing acupuncture in Oriental medicine. Regarding delivery of service, regarding the herbal remedies, as I understand you to state, that the federal government stopped regulating, and do you think that should be handed to care by CAM providers because herbs can be divided into therapeutic and nutritional. If I try to use this to divide it into two. So how do we do that, in your opinion?

MR. DUGGAN: I think we have to start in the grade school, with individuals relearning their relationship to plants and nature. So you start from food and you begin to move from food to plants, and then you define the line where you have some very highly specialized folks who know a great deal about specific herbs. I think we start that conversation in the wrong place by turning plants into products, and we have just been approved to start a three-year graduate degree program that will address these issues, both for Eastern herbs and Western herbs. But to recover that plants are part of the ways that we learn to heal itself, and that all the foods we eat are plants. What we have done in this culture in a reductionist way is turn the plant into a product where we are looking for the active ingredient. That is not the culture of the medicine that I learned. It is the culture that the medicine I know about is being socialized into. So the policy issue would be how do you restore an awareness of plants as healing and then begin to define where is that line between what is food, what is part of every-day grade school, high school learning, and what must be professionalized. And I think we are just beginning to explore it.

DR. TIAN: By the way, regarding the quality control of the herbal product, at the national level or at the state level, how can we do that? Because there is no such organization or like a consumer report.

MR. DUGGAN: That is why I recommend it. I think there needs to be a separate agency so the questions are addressed differently, because there is a major, major issue here of both the quality of the products, whether the products are properly labeled, all of those issues. Ideally, the industry would take it on itself, and there needs to be an agency that will support that. It is a major issue in Chinese medicine.

DR. FINS: Bob, I don't want to sound redundant, but this is the fourth time I have asked this. I agree completely with the two major points you made of first empowering the patient, and how important that is, and I never realized this until I was a patient. I mean as a physician, we can pay lip service to it, but I never realized. I think that is extremely important and one of the major reasons for use of CAM. The second thing is education, and as I brought up before, I just have the feeling that we are failing in education for lifestyle changes. I know, and you know more than I do, that there are a number of private organizations. Ernest Winner of the American Health Foundation was a major proponent of going into schools and giving education, and yet somehow it doesn't translate into lifestyle changes in the adults. So I am going to ask you specifically should this Commission be even considering the step of asking our legislators to mandate that there be classes in nutrition and lifestyle, wellness living, in all schools? I mean should that be part of a national education policy? How do we do this?

MR. DUGGAN: Absolutely. Absolutely. It has to start from the first grade, and it has to start with awareness of breathing, of drinking, of sleeping, of eating. The clinical experience that came to me the other day, talking about women's medicine, a woman brought me in a pile of clinical reports from the best medical centers in this country and from every one of the notable CAM providers in this country, a report. She had a series of vague sympto

MS. It was 2:00 in the afternoon, and this was a highly educated, highly successful, wealthy woman who could afford that stack of reports, and it was 2:00 in the afternoon, and I realize you have been sitting here working hard all morning, and I don't know how healthy the schedule is, and I said what have you eaten? She said a cup of coffee at 7:00 this morning. What did you eat last night? Hamburger. When did you last get some exercise? Three weeks ago. After a while I said do these symptoms ever go away? A long pause. When I went on vacation in Canada, they went away. So, yes, absolutely. And I think insurance must de-incentivize the providers from covering that stack of reports, without asking the basic home-grown question, are you taking care of yourself?

DR. FINS: Well, I am just trying to think of some specific question. On my automobile insurance, if you take a course -- in my case, my wife takes the course for both of us, I don't know that works, but -- [Laughter.]

DR. FINS: But anyhow, she takes the course and we get a 10 percent reduction on the insurance.

MR. DUGGAN: Same thing. Absolutely.

DR. FINS: Do you advocate things like taking a course in wellness --

MR. DUGGAN: Absolutely.

DR. FINS: -- and then there would be a reduction in your health care policy. It would have to be a government plan or something.

MR. DUGGAN: But you have to watch cherry-picking. You wind up getting only the educated that lower rates, and that transfers the rates. That is why I think you need a whole session just on the economics because graduates of our school are being socialized into an economics that doesn't serve what they are trained to do. And you are absolutely right, that is a very complex issue, Bill, and it should start from the first grade, though, and you should mandate that there be wellness, and I don't mean prevention, because we are not talking about 30 year out prevention, we are talking about the sense of wellness today so it is an immediate, same-day return on investment. I know from my food that I am getting back and I feel better. I play better football in high school. All of that should be integrated. But this cannot start with the 50 year old who is then in trouble.

DR. GORDON: Just one more question.

DR. FINS: But I guess, to be more precise, I am saying my perception, and I could be wrong, is that the current policies are not effective enough. Do we need to look at more innovative policies and maybe more legislation? I am not a great fan of overwriting federal legislation, but is this a case where we need to recommend some mandates in educational procedures?

MR. DUGGAN: I think to get it started, there are going to have to be some incentives to make it move, because my experience is the institutions will keep doing what they are doing, unless there is some leverage forced into them, to have them do it differently. So you have got to find those tiny leverage points that push in the awareness of Ayurveda and naturopathy in the second grade. Why should I have a child saying to a nurse I know about the pulses, and starts to tell the nurse about the 12 pulses, and the nurse goes quiet, because this child has grown up with Chinese medicine. And when the nurse is reading the blood pulse in school in the third grade, the child says, oh, I know all about the pulses. And the nurse doesn't know what the child is talking about. We now get a significant number of, I think it is 20 percent of the new entrants to our graduate degree program each year, come straight out of college because they have never in any significant way experienced allopathic medicine. They have been treated by herbs and acupuncture since birth. They come straight in to school, they have no awareness, the thought doesn't cross their mind. You are absolutely right, though.

DR. GORDON: Tierney?

DR. LOW DOG: This sort of dovetails because I agree very much about where the culture of plants comes from, and all of the products that are driven today actually come from traditions that use them, and ointments, unguents, teas in very simple for

MS. My question would go to any of you about products, because if we are talking about access and delivery, part of that has to be about the delivery of product. I know that many CAM practitioners make a significant amount of their income from the sale of products, and many companies actually specialize in just providing products that can only be purchased through a provider that you can't just go and get at the health food store. Does that affect delivery of those products? Is there any concern about that? I would just like to hear some comments on that since we are talking about access and delivery, and if you are restricting access, or you are basically funneling people through, saying the only product you can get is from me, you can't get it through the health food store, how does that affect this whole dialogue of access and delivery? Anybody?

DR. HUDSON: Well, one of the -- I think there is the medical aspects of your question, and then there is, I think, conflict of interest aspects of your question. In terms of the conflict of interest, yes, I think there is a conflict of interest when you provide and sell products, you recommend products that you sell out of your office. And naturopathic physicians do that. But I would also point out dermatologists, ophthalmologists, optometrists do that, and probably others that I'm not aware of. An OB-GYN who recommends a pelvic surgery that they then perform is also potentially a conflict of interest. So I think there is a conflict of interest, and I think that right now we are sort of relying on an honor system, and maybe as more money is involved and companies like Phillip Morris own Boca Burgers and other things, that maybe we will have to attend to this in something other than just an honor system. The medical aspect is that there are herbs and nutrients and doses of herbs and nutrients that people should not be prescribing for themselves, or taking themselves, as you well know. I might treat a woman even with something as simple as PMS and I recommend a certain combination of ingredients, and she will say, oh, I already tried Chase Tree or I already tried Natural Progesterone, and then I will clarify, well, what dose did you really use, and for how long did you really use it? And clearly she was undertreating herself, and merely just doing the same items in a different pattern, in a different frequency, in a different strength, yields completely different results. The health food store aisle medicine is different than medicine delivered by a knowledgeable practitioner, and I think the consumers themselves are at the moment kind of determining, well, when do I want to try this myself, and when do I want to go to a practitioner? And that is really kind of an individual choice issue, which I think at the moment is okay to leave it that way, the individual choice. They would get better results, often, if they didn't just aisle medicine, natural food store aisle medicine. But I think just as we educate people better and better and better, it will become clear. That is one of the things I tried to do in my book was have a section, when should you see a licensed health care practitioner. Not when should you see an MD, but when should you see a licensed practitioner. Well, when your bleeding gets to be this way and that way, and your pain gets to be this way and that way, that is when you should not be using the things in this book, and go talk to someone. I think just education will help go a long way towards making those distinctions.

DR. SCHNEIDER: In the field of Vedic medicine, I would say there are three levels: One is lifestyle; second, is over-the-counter products; and third, would be professionally recommended products. The first, which is probably the most important, is the area of lifestyle, that is diet and daily routine are very important to prevention and maintenance of well being, and those don't require a doctor's prescription, but they do require education from the ground up. At our university, by the way, there is a primary and secondary school where all the children from age five years to 18 years meditate together twice a day, and also have other aspects of healthy lifestyle, and they are much more healthy and productive in their school than comparison children. So that is the first, lifestyle, which is free, and doesn't require a professional intervention, and it is not a profit center for anyone other than the grocery store owner, which knowledge everyone should have from the ground up. Second, in the field of Vedic medicine, there are over-the-counter products available where people can make their own choices according to their own knowledge, and hopefully they have had some basic education, and those are products that can be used by the general public and, as Tori mentioned, are in combinations that are useful for the public. The third level, there are combinations and items in Vedic medicine as in other traditions that do require a high level of expertise to use, and when used properly, they are very effective and without harmful side effects. So I think one has to have that third level. Whether or not a practitioner sells those himself or herself, or whether that is a separate dispensary, modern pharmacies are in most cases separate from physicians' practices, that could be done also in the field of natural medicine. I think that would be fine. Of course, it is also true that a physician often recommends procedures that he or she performs, so there is a precedent in modern medicine for that also. But I don't think that is the major issue, profit, and it could be dealt with in that way.

MR. DUGGAN: I would simply add that I would favor you taking policies favoring disclosure rather than setting policies or regulation. Disclosure, disclosure, disclosure, so it is out front, whatever. If you make a 15 percent profit on your product, disclosure rather than regulation.

DR. GORDON: Thank you. Effie, Charlotte, and then Joe.

DR. CHOW: I really appreciate the presentations, and the wellness and the focus on the whole person with all of you. I am familiar with some of your work, and I appreciate it. There is a big question that as CAM becomes more accepted, and we strive to survive and go through research and become validated, and that we like our practitioners to survive, of course, in the same lifestyle manner that we were used to, and that is wonderful, Bob, your students are doing that. Then there is a population we are talking about. It sort of seems like only the middle class have access, and even then it is tough. What are you folks doing in your own institutions to help that, reaching out to the poor and the ethnic groups, and as someone mentioned earlier, it was not just the ethnic group. I have real concern because I have been in this a long time, and it seems like it is the middle class were sort of forced into it. But if you folks could mention -- and what kind of recommendations do you have to do that?

DR. HUDSON: I have done a lot of thinking about that one. I think it is a responsible thing to do, to think about one's privilege, and who is privileged to work with you from an economic point of view. In my own personal case, in our clinic, just from the physicians' standpoint, we have three tiers of pricing, you might say, and it is based on experience. We have a resident, and her fees are a certain level, and then we have the people who are second year or third year physicians, and then the third level. So there are three different pricing categories that people could have the option. There is quite a bit of difference between those. Secondly, for myself, I work one day a month at a rural clinic where the prices are two-thirds less than my normal urban prices. Then I also work at the naturopathic college that has a sliding fee scale. In our clinic, we have payment plans and outreach in terms of some free clinic time in different communities in the Portland area, whether that is by ethnic group or economic group, or some combination of both.

MR. DUGGAN: We put about $200,000 a year, about 5 percent of our budget, into running an inner city clinic, and we add to that specified time among all of our senior clinical year students to work in those at about five or six clinical programs in Baltimore. I am aware that at least six or seven of our graduates have established similar clinics, and that is why I mentioned the policy recommendation of promoting the return to pro bono service. I do every Friday morning in an inner city clinic, to be of service, and a good number of our graduates do. So it is a very specific policy of the school to promote, and our board has been very deliberate, that whatever we are doing in Columbia, Maryland to demonstrate this among the very economically privileged, we must be doing at the corner of Pennsylvania and North in inner city Baltimore, to show that the same world applies and serves, and actually saves a fair amount of money for the city of Baltimore health system.

DR. HUDSON: I want to add just one brief thing. It is one thing that could go a long way for people accessing naturopathic medicine, is that student loans -- we cannot go, after we get our $100,000 student loan, we cannot go work on a reservation or in the neighborhood in Baltimore and get any part of our loan forgiven. That would be something that I think you would see a lot of naturopathic physicians wanting to go to those areas because of the natural resonance and compatibility with ethnic medical practices. In those communities we have had a lot of naturopathic physicians wanting to go to rural areas. I mean they want to be around all those trees and plants.

DR. SCHNEIDER: Our institution is part of a federally funded CAM center which is a consortium that includes two of the nation's four historically black medical schools, and this CAM center specializes in research and demonstration practices of CAM in high risk minority populations. For the past 12 years, we have conducted a series of randomized trials --

DR. GORDON: You said the magic word.

DR. SCHNEIDER: We have conducted a series of randomized trials, the only trials to date of mind-body approaches in high risk African-Americans for the treatment and prevention of cardiovascular disease. Some of those reprints are in your packets. So we have been very involved with the nation's historically black medical institutions in rolling out CAM approaches in lower socioeconomic, ethnic communities, particularly African-American communities. Our next initiative is in Native American communities and Hispanic communities and other ethnic communities after that, as part of our federal CAM center.

DR. CHOW: We appreciate your volunteerism, but perhaps if you have -- that is what a lot of CAM people are doing now, you know, and if you have recommendations, specific recommendations to see how that can be rectified. I mean continue to volunteer, but how can we make it more kind of viable? I would appreciate that.

DR. SCHNEIDER: I think it is reimbursement policies. Many of our participants receive their care through Medicare and Medicaid, and if those reimbursement policies were in place for CAM, we and others have shown high levels of patient satisfaction, compliance and efficacy.

MR. DUGGAN: Actually, in inner city Baltimore, I think in the project we run, if we were looking at outcomes, cost outcomes and quality of life outcomes, rather than mechanism, we would show that the cost of care for the individuals coming through our clinic through the Medicaid system is probably a great saving. But the design of a study to show that is extremely complex and expensive. But we are quite positive we save the city and Medicaid an enormous amount of money each year through that, often by simple education.

DR. HUDSON: I would echo that Medicare-Medicaid reimbursement is nonexistent, basically, for naturopathic medicine.

DR. GORDON: Thank you. Charlotte. SISTER KERR: Yesterday I said that I thought the role of the prophet was one of imagination, and so I want to ask you prophets, can you imagine any other ways to help to help make CAM more easily accessible, other than by insurance reimbursement or Medicare or Medicaid? And is reimbursement really the solution? We think about reimbursing acupuncture, naturopathic, but what is the basic nutrient? What are we going to do about reimbursing people who buy bottled water, or we may need oxygen masks soon to go into certain sections of America? Maybe that will be part of a reimbursement. Or should we subsidize the people who are buying organic food for their medicine? So I want to ask you, either now or in the future, to send recommendations for other ways. Bob did cover that already, I think.

MR. DUGGAN: We did a small study, Charlotte, as you know, with the corporation where we put in one of our graduates who happened to be a tai chi teacher, but also was still making money as the key personnel benefits director of a fairly significant corporation, put in minor CAM interventions, and that corporation cut costs by 20 percent over five years. What we believe actually happens with the educational component of CAM is that it becomes water cooler medicine, and so people learn around the water cooler simple ways of dropping out of the sick care reimbursement system. The insurance reimbursement, the mechanism in that is that it is the self-insured large corporations that understand where the dollar saving is. It is not the insurance companies. Almost all the insurance companies are making a quarter point profit on a transfer between the corporation and the beneficiary. The person paying the bill is the large corporate employer, and the moment they realize that they can 20 percent off by simple educational programs, when you are looking at 100 percent increase over 10 years. So it is the same thing that happened with Allied Signal in '87, in the development of managed care and the explosion of that. Some large corporation is going to take it and do that. I don't think Medicare and Medicaid can do it. The ideal thing would be for Medicaid to save a lot of funds by doing that. I think it has to happen in the private sector first. But that is why I urge a session on rethinking the economics because all the economics now are designed to disempower the patient, disempower the practitioner. I asked a group of our graduates yesterday, thinking of today, do they want me to speak for insurance reimbursement? And to a person they said no, because it perverts us and our patients. They don't want insurance reimbursement, and the other side of the coin is the group you are talking about, Effie, the poor, those who have no access to this, we have to find a mechanism that provides that access. But the driving force where the big money is, is disincentives to wellness across the board. So, yes, you need a very good economist to sit down and rethink the policy or CAM is simply going to look like the rest of the health care system.

DR. GORDON: I have a question just before we move ahead. Do you have a recommendation for someone whom we could work with on that?

MR. DUGGAN: I know of two. I will check them and get them for you. But I think it is a very important conversation to have. There is somebody at Princeton, and I don't want to mention names, but there are two or three people who understand that issue.

DR. GORDON: And we very much welcome working with you as well.

MR. DUGGAN: I will get that for you. Thank you.

DR. HUDSON: We probably need new Nintendo games, would be my guess, on this topic. But more seriously, other ideas that don't have to do with reimbursement might be again coming back to this education in the schools. I think that is really where it needs to start. I see that. It is very sad for me in my practice to be talking for the first time to a 50 year old woman about calcium in her diet, and who already has osteoporosis, when it was a totally and absolutely preventable disease, if we had been talking about it much earlier. Perhaps discounts on disability insurance for people who have certain health practices. Perhaps some kind of, I don't know if it is a tax benefit or some other benefit, if you have a garden, a vegetable garden where you are growing food. Perhaps a tax benefit to companies who are involved in the natural products industry. And then I think always leadership, you know, leadership in the form of our president, our senators, our legislators, that somehow if something could catch on and one of them really popularizes it and becomes a leader in this area. That is kind of what we need, is a leader.

DR. SCHNEIDER: Besides education and reimbursement, perhaps the most important issue would be access to CAM services for everybody, and that would be in terms of practitioners. Now it is not legal for many or most CAM practitioners to practice their art or science in most states. Much is practiced, but not legally. If those practice laws could be liberalized, like in Minnesota, so CAM practitioners who are certified and gone through proper training could practice, I think that would go a long way outside of reimbursement and education. After all, most of the $60 billion a year spent in this country already on CAM is not reimbursed by third-party payers, and is out of pocket, and almost half of Americans use those services now if they are accessible.



MR. Duggan's testimony talked about sort of understanding fundamentally what this movement is all about, and that prompted me to look at

DR. Hudson technically a little differently, and I was wondering if you have had the opportunity to think about the relationship between the CAM movement, because I think demand really drives access of delivery, and the development of the CAM movement and the women's movement in self care and natural childbirth. There is sort of an implicit message and I was wondering if you could say more about that and help us make sense of this phenomenon a little better.

DR. HUDSON: Well, you can help steer me if I get off track here, but I can, I think, best try to answer that by my own experience. People often ask, you know, how did I become a naturopathic physician, and my answer is that really it is I am 48 years old, and my life experiences include graduating from high school in 1970 with the first Earth Day movement. It was also in the early '70s you had the feminist movement, the self help movement, the back-to- the-land movement, and all those have converged, I think, in my life at this age to evolve this interest and passion and drive about alternative medicine. I think those are probably common forces on many people, both practitioner and consumer. The feminist movements, women's movements, is certainly about empowering one's self and taking responsibility for one's life, and being more self directed, and calling upon inner forces to fully evolve. And I think all that language is applicable.

DR. FINS: And I would just add one other point, is that the feminist movement has been very good at getting us to ask questions about hierarchies and power relationships.


DR. FINS: So I think it would help for us to sort of put this new movement into the context of movements with which we are more familiar, and we might have had 20 or 30 or 40 years of experience with because there is a lineage, and I think your testimony sort of raises that. So thank you.

DR. HUDSON: Thank you for asking that.

DR. GORDON: Wayne and Tom. We need to end by 12:30, so we can have an hour for lunch, and if we have time, but I really want to end promptly so we don't hurry through our lunch.

DR. HUDSON: A good health practice.

DR. JONAS: Well, as usual, the profound questions have already been asked, so I will go back to the mundane. [Laughter.]

DR. JONAS: I had a question for

DR. Schneider. It seems to me like you have pretty significant data, at least as good as the orange data, in terms of significant improvements in health and cost benefit, and this type of stuff, and I am just wondering, have there been any insurance companies that have picked up and said we are going to do a demonstration project, or we are going to incorporate this like has occurred in that program that we just heard about?

DR. SCHNEIDER: Yes, there are several large corporations, several Fortune 500 companies, which now reimburse their employees for learning the TM program, the major mind-body approach of Vedic medicine, and they do that because of noted reductions in health care costs and improved productivity. There are indemnity insurance companies and HMOs are considering Vedic medicine, but right now it has been largely in the corporate sector and self-insured sector.

DR. GORDON: It would be useful for us to have that data as well, in terms of making recommendations.

DR. JONAS: May I just extend that to the other panelists, to see are there others that have had that picked up by insurance companies or corporate companies, their entire practice? I am not talking about elements of it, but the practice itself? I think we have heard a fair amount, actually, about some of the naturopathic stuff that is going on in the Northwest, but has that happened, Bob, in D.C.?

MR. DUGGAN: It is getting a major commitment with the large corporations. We have two relationships with getting the research component in them, working with making the distinction for corporations between -- what we have worked on is making distinctions between acupuncturists who are educationally-oriented and acupuncturists who are technique-oriented, and what we know in that study, we did the same study at six clinics. In all six clinics, the symptomatic outcomes were the same, but the two clinics where there was a lot of education, the patients had a different level of satisfaction. It was a very different statistical outcome, and we have two corporations now, in fact, one very large corporation shifted their whole insurance program recently, and we had designed a very specific program which led, if the practitioner didn't educate people in self care, they wound up having to deliver free care. And when the corporation tried to end that program, although as far as we know, no one is delivering free care, it has been very successful, the corporation couldn't end that. They couldn't fold it into the brand new national program, and they had to put that as a special set- aside program for them. A company with about 4000 employees. And we were surprised that the benefits manager found that she could not shift that design that was in there.



DR. JONAS: Was it because of the --

MR. DUGGAN: Educational component.



MR. DUGGAN: The employees protested when it was about to disappear.

MR. CHAPPELL: If you could just respond or brainstorm with me for the couple of minutes that I have got left on the question of how do we provide the supply of funds for the freedom of choice of services? If it is not the reimbursement model, and we certainly struggle with that, then the only other things that I know of that are going on in our society are Social Security, which is a deduction we could have for wellness promotion, as well as Social Security. We could have a payroll deduction at corporations that are income tax deductible to those corporations that are providing some contribution to that individual's wellness program. I mean, for me, this has been a self-help, self-care initiative for the 20 years, 30 years that we have been around, and it still is, in my opinion, no matter how much we work with the professional context of this, it is still being driven by consumers, increasingly self-educated, self-regulated consumers. So I am struggling with how can we put money in their hands, rather than that in private managed care hands, who will tell you how much you are going to get for your procedures and so on. So I am thinking of how do we get the supply of money into the hands of the consumers first.

MR. DUGGAN: I believe, I don't know the exact statistic, but the amount of money spent in the six months before death is probably 25 percent of the national health care budget. Deeling Evangeles' [ph] book in 1974, "Limits to Medicine," points out that a culture that attempts to prevent death will spend itself out of existence in that attempt. The cultures that have a different attitude towards death spend about 8 to 9 percent of GNP. We are close to 16. So I say to consumers, if you work to reorient the concept with the aging population, we have to deal with this. I was at a meeting the other night of the leading corporate executives in Howard County, Maryland, and we had the head of a hospital system and the head of an insurance system. The head of the hospital system was talking about the new high tech care coming on line. The head of the insurance system said, well, we can't afford to pay for all of that. We don't know what we are going to do, and I thought I was going to have to get up and say something, but thank God, one of the physicians who is head of the hospital physicians' practice got up and said, well, everybody in the room has a lot of suffering, and we are all going to die, and we have to rethink our relationship to suffering and death. I think the economics would show if you reorient the way we deal with dying, and if you reorient the way we deal with functional, nonpathologic visits to any health professional, you then move a significant economy into that free base to support wellness. That is why I am talking about the economic design has to be shifted. My mother -- and I went it through this year with my stepmother -- she was ready to die, and I wasn't there, but the automaticness was for her to spend three weeks in a hospital where we had to get her back off the tubes, rather than have said, mom, it is time for a good bottle of Irish whiskey. Let's all sit down together, we are going to let you die at home, without all the tubes. She was 91. Now I have been through that three times with family in the past year. The enormous expense in those last six months of life, well documented, is where the pot of money is. And the other pot of money is in whatever percentage it is that corporations spend on MRIs, when it is pretty clear that the person is not eating breakfast, lunch and supper, and they have a headache. Now that is the educational component. The money is there, it is not adding a new tax base to finance this. The corporations aren't going to do that, the government isn't going to do it. We have to understand where the pot of money is that has to be shifted. That is why I put in as one of my recommendations a strong sense of the relationship of CAM, hospice, and palliative care, so that we reshift -- and if we don't do that pretty quickly for the elderly population, we are not going to afford the care that is demanded for the aging population. So there is a pretty sophisticated economic analysis that goes on here. But the money is there. It is just now being used in the wrong ways.

DR. GORDON: Effie?

DR. CHOW: I am very excited about the gist of this conversation because we have been primarily talking about how can we research CAM, and talking about techniques and methodologies, and I would love to -- no time for discussion now -- but I would love for you people to send more input on this avenue. For example, Tori, you talked about, let's teach people to go back to the garden, like have your own vegetable garden, because organic food stores are very expensive.

DR. GORDON: Thank you. Thank you all. Thank you for opening the discussion and deepening it for us as well. We will adjourn now for lunch until 1:30. We will start promptly at 1:30. [Lunch recess taken at 12:30 p.m.] + + +