GROFT: I can't believe how many speakers we have arranged. It's going to be very very busy. I'm Steve Groft and I'm the Executive Director of the White House Commission and I can't welcome you to Seattle, but thank you for hosting us. It is truly our pleasure to be here. We started talking about this right before the Commission had its first meeting back in July and I really would like to thank the people here in Seattle and the King County 2010 Planning Committee and their council that have been working with us these many months.

We started virtually from not having anything scheduled for Seattle to what you see today. And I think you all have received an agenda and all the speakers, you can see the amount of time that has gone into trying to arrange a number of presentations. All subjects that are particularly important to the Commission as we formulate our recommendations and prepare them for the President, whoever it may be, in an interim report next July, and then by March 7th of 2002 we will submit our final report to the President and to Congress for their action.

At today's meeting, before we have introductions we expanded the Commission or the President did by amending the initial executive order for the Commission by adding five new members. And three of those are here today. Veronica Gutierrez, and we'll get back to all the people in just a minute; Linnea Larson; Dr. Ming Tian; and there are two others who are not present today, Dr. Donald Warren from Arkansas and Dr. David Bressler from Los Angeles, California. So they'll be joining us at future meetings.

I would encourage you to visit our Web site. I believe we have information in the package of information. Everything that we do will be up on the Web site, so the transcript from this meeting, is the transcriber here by any chance? We're missing a transcriber. We will do something, whatever we can, to get the information up. We may scan the written reports that we receive from you and put into the Web site. But please check out our Web site on a regular basis. You can keep up with what's going on as well as write us and let us know your feelings toward the different issues. We will also put up the interim report for you to comment on and we will revise the report per your comments at that point.

We do have a limited number of slots for individuals to speak. I don't think there are a lot, but if you're not scheduled to speak and you would like to have about three minutes I think it is at the most, please register at the desk and we'll fit you in one of these two days, a very short period of time, so take advantage of that if you're not scheduled.

We will do the same tomorrow, except tomorrow we start at 8:30 and end at 2:00 so that there will be slots available at that point also.

At this point I just would again like to thank you for coming to make our trip successful. We can come here and nothing can happen, but it's only through your participation and your efforts to give us information that we can learn the tremendous strides in activities that have been going on here within Seattle, Washington, and Oregon, really has been tremendous. And I think that was one of the reasons that led us to come out here. It just has been tremendous. I want to just thank Sheila Quinn in particular for all the work that she has done. She has been really outstanding. Pam Snider and Lori Bielinski, three of the people who worked on very very early to help us get started. And there are several other people who you will hear from later today.

So at this point I'd like to turn it over to Dr. Jim Gordon, our Chair, and he'll take us through the next two and a half days, or two days. Thank you.

GORDON: Good morning everybody. Before we begin, let's just sit for a moment quietly. Thank you. Our work here is about being present to you, with you, with ourselves. And so we begin the Commission meetings sitting quietly so that we can truly be here, letting go of the outside and being here for each person who is going to come be with us.

It's really been wonderful so far these last few months with the Commission. We've had an extraordinarily interesting time. And what we're finding as we reach out to people all over the country and ask them to come, people, like those of you who are here, are saying yes. It's time to really take a look at what so many of us have been doing for the last 30 years or 20 years or 10 years. Let's see where we are and let's see where we need to be going. And our work, as you heard from Steve, our work is really to take what we will learn here today, tomorrow, what we have been learning, what we will learn over the next year and some, and to digest it, assimilate it and then to offer it back to all of you for your thoughts, critique, and then hopefully to offer it as well, not hopefully, to offer it as well to the President and to Congress as concrete recommendations for the directions that we should move in to make a kind of comprehensive health care. One that is informed, not only by specific complementary and alternative medical practices, but by the world view and the philosophy that is embodied in those practices. To make that kind of health care available to everyone in the United States. So we have a large and really very joyous mission, and it's great to be working with you on it.

It's wonderful to be here in Seattle. I've worked in Seattle now for 25 years. I used to come out here and work with youth advocates, with runaway and homeless kids on the streets of Seattle. So all kinds of memories come back and it's fun for all of us. We had to limit the number of commissioners who could come, partly because people wanted to come to Seattle and partly because everybody was so, to use a technical term, blown away, by the response and by the response of your community and of leaders in your community to the Commission coming here. There is a sense of tremendous excitement that we have, that all the Commissioners have.

Because there has been such a great response, we are going to have to be a little tough minded up here and ask you to be tough minded too in presenting, those of you who are going to be presenting to us. And we're going to stick very carefully to the time limits here. On my right I have Michelle Chang who used to work as a bone breaker back east and she is going to be, she may look very gentle and nice, but underneath. And she's going to be making sure we all stick to the time limits. So what we really passionately want to hear from you is what's the essence of the message. And as we ask questions, we've said we've learned from previous meetings it's important for us to have time to ask you the questions and for you to give the answers that will help to guide us as we move ahead.

We'll have panels of four or five people and after each, we won't ask questions after each speaker. We'll ask questions at the end of the panel. And we'll have about eight minutes. And all of the Commissioners will have an opportunity to ask questions.

I'd like to introduce my fellow, that's not quite right, my brother and sister panelists. And each one from the right will just say a word or so of greeting. First, Tom Chappell.

CHAPPELL: Good morning. I'm Tom Chappell, the co-founder of Tom's of Main. I'm very interested in being with you this day and a half to hear the content of your stories, your experience and your real convictions about this topic. So what you have to share will be very meaningful to what we can take back.

GORDON: Thank you, Tom. Tieraona Low Dog.

LOW DOG: I'm Tieraona Low Dog. I'm from Albuquerque, New Mexico. And I love Seattle and I've been fascinated with what's going on up here in your state of Washington and how you're addressing the issues around complementary and alternative medicine. So I think you have a lot to teach us today. And we certainly are here to learn and share in what your experiences are. So we want to thank you for letting us come to your community and coming out to help us.

GORDON: Effie Chow.

CHOW: I'm Effie Poy Yew Chow, President of East West Academy of Healing Arts in San Francisco. And Seattle is kind of my second home and so your comments and your creative thinking will be very essential for us, and thank you for having us here.

GORDON: Veronica Gutierrez.

GUTIERREZ: I'm Veronica and my husband and I have been chiropractors in Washington state for 37 years. We've seen a great shift in consciousness over those years towards complementary and alternative medicine and I'm just excited about being a part of taking it even one step further.

GORDON: This is Michelle Chang who is our Executive Secretary, and Steve Groft is our Executive Director. Linnea Larson.

LARSON: My name is Linnea Larson and I have been working as a social worker. I'm very pleased to be here. My particular interest is in really hearing with discernment what you have to bring to us, specifically with reference to doing anything with the underserved. GORDON: And Xiaoming Tian.

TIAN: My name is, everybody call me Ming, it will be very easy. I was trained as a sports medicine orthopedic and a bone pathologist and I am interested in Chinese medicine and I was trained as an acupuncturist and herbalist in China and practice in Bethesda and I am the director of the Academy of Acupuncture and Chinese Medicine. And ten years ago set up the first acupuncture clinic for acupuncture. So besides our clinic and we handle about 10,000 patients every year, visits. And also we serve acupuncture for NH patients starting in 1991. We have a grant of research for fibromyalgia so we treat fibromyalgia patients. And also we have done the study of Chinese herb to treat arthritis, fibromyalgia and osteoporosis post-injury. Thank you.

GORDON: And Joe Fins.

FINS: Good morning. I'm Joe Fins. I'm a general internist and medical emphasis from New York and just want to add my thanks and my great delight in being here with you today. I think we're going to learn a lot, and this is really in many ways the epicenter of this kind of practices in the entire country, so we're really thrilled to be here. So thank you.

GORDON: Thank you all very much. And I guess I'm Jim Gordon. I'm the Chair. Aside from being a frequent visitor to Seattle, I'm a physician in Washington, D.C., a psychiatrist, and I work with Chinese medicine, nutrition, meditation, herbalism, western herbalism, manipulation, many things. So I feel very at home in nature and at home in the natural climate in the Northwest.

We're going to begin by introducing four speakers who are going to set the stage for us today. Richard C. Kelly, Robert Harkins, actually it's more than four, four groups of people, and from the King County Council, is it Maggi Fimia, Kent Pullen and Greg Nickels, and Joseph Pizzorno. They're all each going to come up there? Okay. So maybe they can sit at the table and then come up one by one.

Opening Remarks

KELLY: Good morning ladies and gentlemen. On behalf of the United States Department of Health and Human Services I'd like to welcome you all to this White House Commission on Complementary and Alternative Medicine Policy town hall meeting. I would like to extend a special welcome to Region X to our White House Commissioners. We'll be spending two days in Seattle. They still have a little bit of cultural adjustment to make. Dr. Fins, a place that has as many earthquakes as we do doesn't really like to be called the epicenter.

FINS: Thank you. I was just trying to be nice.

KELLY: I particularly want to welcome all the individuals that have come here today to testify. Your comments and testimony are very important to the success of this venture, as the Commission will ultimately be making recommendations for national policy. I regret that some of our Washington state legislators and other officials who are interested in being here could not be due to their required attendance at the Washington State legislative conference and I bring their apologies.

As you all know, the task of the Commission is to provide to the Secretary of Health and Human Services, Donna Shalala, my boss, recommendations that can be transmitted to the President for appropriate administrative and legislative initiatives to improve the health care and wellness of all segments of the United States population. By signing the Executive Order 13147, President Clinton lifted the issues related to complementary and alternative medicine, CAM, to the highest levels of consideration in the federal government. Today we all have a very interesting and important opportunity through the partnership inherent in this Commission's structure to fulfill the purpose and spirit of the executive order. I look forward to hearing the testimony today on how we can assure that public policy maximizes the benefits to Americans of complementary and alternative medicine. Issues such as increased research on CAM practices, delivery, and access to CAM services, dissemination of information to both providers and consumers, licensing, education, and training of providers, and reimbursement for CAM provider services will all be addressed in these hearings.

The Northwest is a unique environment for the integration of conventional and complementary and alternative medicine. The confluence of cultures which enriches our region has also contributed to the cross fertilization of health traditions. In the next two days you'll be hearing testimony about our unique history and partnerships. And I would urge the Commission to carefully consider the testimony of a region that has taken a real leadership role in the integration of conventional and complementary and alternative medicine.

I am very proud of the contribution that HHS Region X Regional Health Administrator Dr. Richard Lyons and Deputy Regional Health Administrator Karen Matsuta have made to this work.

It is also my hope that the Commission will work in concert with the goals and objectives of Healthy People 2010. This is our department's blueprint for our nation's public health. Healthy People 2010 seeks to increase life expectancy and quality of life as well as to eliminate health disparities among different segments of our population. These differences occur by gender, race or ethnicity, education or income, disability, living in rural localities and sexual orientation. Our department is dedicated to bring equal access to comprehensive, culturally competent, community based and integrated health care to every person in every community across the nation, especially those who are now uninsured and undeserved.

Health traditions individually have roots which go thousands of years deep. But our journey together is just beginning. I thank you all for coming to participate and I thank the White House Commissioners for contributing their time and energy to this effort to create a more integrated health care system for all Americans in the first decade of the twenty-first century.

BIELINSKI: Good morning. On behalf of Washington State Insurance Commissioner Debra Seen and Chief Deputy Robert Harking who is home ill, I want to express thanks to the White House Commission on Complementary and Alternative Policy for selecting our state as a site for one of your town hall meetings. Washington State's Office of the Insurance Commissioner has played a founding role in the efforts to integrate health care. But we should also give credit where credit is due. Washington's health care consumers are among the nation's effective advocates for access to complementary and alternative health care. Credit them for providing the support to policymakers that led to the passage of the nation's first law that guarantees access to CAM providers within health insurance plans. That law faced a long and determined challenge from the insurance industry, but Commissioner Sean's strong advocacy for this legislation never wavered and ultimately the U.S. Supreme Court upheld its implementation. In addition to its landmark access law, Washington has the greatest number of regulated CAM professions: acupuncture, doctors of chiropractic, dieticians, massage therapy, naturopathic physicians, and licensed midwives. But even in our state we are still only at the threshold of a new health care era. For that reason the White House Commission's work is timely and important, developing recommendations for practitioner education and training, coordination of research, getting research data to health care professionals, and finally, providing guidance for appropriate access to the delivery of CAM medicine.

What we see here in Washington is the public's continued call to insurers and providers to end what they see as increasingly irrelevant decisions in the health care system. We see our mission as one that listens to that call, and we are pleased that the White House has heard it as well. Each day brings new discoveries and treatments. Our opportunity as public officials and policy makers is just to facilitate access to that care and for the benefit of America's consumers. Thank you for listening.

NICKELS: Good morning Mr. Chair, Commissioners, ladies and gentlemen. My name is Greg Nickels. I'm an elected member of the Metropolitan King County Council and I chair the King County Board of Health. My role today is simply to welcome you to our region, to our fair city here, and thank you for honoring us with your presence. I was very pleased in looking through the schedule that you have set out for the next several months at the number of stops that you are going to make throughout our great country.

I am a local politician. I believe in action at the local level. And I believe that by taking action at the local level we make it safe for our states and our national government to take a look at innovative and new policies. We've done that here in King County. Our Board of Health has existed since 1996 and I've had the honor to be Chair of the Board since that time. We were one of the first, we think perhaps the first, Board of Health in the United States to have a naturopathic physician as a member of our Board of Health. We're very proud of that and you're going to hear from him in just a moment.

But we also, as a King County Council, are very proud of some of the investments that we have made to explore natural medicine, alternative medicine, complementary medicine, and to find ways to integrate traditional medical practices known in this country with those alternative and complementary medicines. And you're going to hear about that today.

Our Council has heard from the 1.6 million people that we represent that our constituents want to make informed choices about how to have a healthy lifestyle and a long and healthy life. Two of the leaders on our Council are going to be here and participate with you today and tomorrow. And I'm very pleased to introduce one of those, Council member Kent Pullen. Thank you.

PULLEN: Thank you. Again, I'd like to echo Council member Nickels' comments and welcome you, Mr. Chairman and members of the Commission. My job this morning is to welcome you and everyone else here today. I want to thank all the attendees, I want to thank our wonderful staff who worked so hard to make this a successful event, and particularly the Commissioners who have come such a long way to be here. I am a panelist down as item number seven, so I'll be making some of my technical remarks at that time. But for now I want to reemphasize the fact that the Seattle area has been a beacon that has lit the way for the rest of the country with regard to health care reform, improving health and reducing the cost of health care. We hope that we'll be able to provide you with information on what we've accomplished and that you'll take that knowledge back with you.

All of you are very powerful and influential commissioners. The recommendations that you will be making will have a profound effect on health care in our country for years and years to come. So your presence is very much welcome, and I, too, would like to thank my colleagues, Council member Greg Nickels, Council member Maggi Fimia, who have been such wonderful leaders at the local level. Again, thank you all, and if any of you Commissioners need any help from us in any way, please let us know. We're here to help. Again, thank you very much, and welcome.

PIZZORNO: Good morning Dr. Chair and Commission members. Welcome to the Northwest. We're honored and excited to have you visit with us these two days. Many organizations in the Northwest have worked very hard together the past two months to prepare for you what we hope will be an interesting and informative two days. And I would particularly recognize the organizations that provided the funding and personnel. King County 2010, King County Council, Region X Public Health, Bastyr University, The American Massage Therapist's Association Washington Branch, The Washington State Chiropractic Association, and the Washington Association of Naturopathic Physicians.

We worked very hard to facilitate all the invited speakers making their presentations in the context of the four categories that you've been mandated by Congress to cover. And through this presentation of information we hope that you will hear fourteen key things that we think are important for you to develop recommendations for. Now before I mention those fourteen things, I would also like to mention that we also hope that you will see here the importance of broad collaboration in making something of this nature possible. You will see collaboration at the local, state, and regional levels of governmental bodies, regulatory agencies, academic institutions, practitioners, public health officials at organizations and payer organizations. We've all been working together for what we hope you will find of interest.

So those fourteen things:

1. CAM is about systems of healing, not isolated therapies. Natural medicine is defined by its philosophy, not by modalities, or by the substitution of green drugs for synthetic drugs. These systems change what we think about and provide health care.

2. Disintegration movement in the Northwest is not only about . . . CAM, it is about mutual collaboration to create a true health care system. Not about limited disease oriented system that today dominates health care thinking and resource allocation.

3. We urge you to do everything you can to facilitate collaboration. And this collaboration is not just about conventional practitioners and CAM practitioners working together, it is also about full integration of public health officials, regulatory bodies, payers and governmental agencies.

4. Research. Research outcomes first, not isolated therapies. CAM is multifactorial. Patient satisfaction quality of life are critical measures. Just as we as a society have reaped tremendous benefit by a huge investment in conventional medicine research, similar benefits will be found by investment in CAM research. Again, the CAM research must be about outcomes, not about single therapies.

5. Level the playing field. Disparity between CAM and conventional medicine education research maturity are directly due to the disparity in federal funding for those activities.

6. Strengthen accountability. Accountability and standards are critical for public safety. Support activities that communicate and respect existing standards in emerging professions and fund activities to improve and further develop those standards. Those standards need to be strengthening the accreditation, practice guidelines, education, not only of CAM professionals providing CAM therapies and CAM interventions, but also conventional practitioners who want to use CAM therapies or CAM systems of healing, they need to have appropriate education. We would have national certification boards with credible testing and credentialing processes.

7. Although this may sound somewhat like number six, it is a key issue here, and that is, we have a great need for appropriate nationwide regulatory standards. We need to have uniform licensure, regulation, and public safety. We need to have national board exams. We need to collect and disseminate information about state regulatory models that are working so that other states can adopt those same kinds of regulatory models. As you are aware, the Constitution delegates to the states authority for the regulation of the practice of medicine. We need to provide advice to those states about how best to do that. We need to develop federal guidelines so that the natural lifestyle of emerging professions can be accommodated and facilitated. Although chiropractic medicine, acupuncture and naturopathic medicine and massage are well developed in this country, there are other natural healing arts that are trying to emerge in this country, such as aervada. We need to provide methodology by which they can develop. Right now the environment is hostile for new professions.

8. We need to help the CAM professions mature. We need to facilitate the development of practice guidelines, credentialing systems, peer review processes, inclusion in federal programs, infrastructure of CAM institutions. A huge challenge here. And if this body of knowledge is to provide health care opportunities that it can, we need to facilitate these processes.

9. We need to deeply engage CAM professionals at all levels of evaluation and decision making. CAM professionals have considerable and sophisticated expertise. They need to be utilized. All health related committees and advisory boards should include CAM regulators or CAM practitioners or researchers as expert advisors, consultants and/or researchers.

10. True integration and collaboration require joint training programs in clinical properties. Practitioners who train together practice together. It's been well demonstrated in conventional medicine where practitioners train together they will practice together. We need to do the same thing to include CAM professionals. We need to support strategies for expanding integrated care settings in which conventional and CAM providers practice side by side, learning from each other and being jointly committed to improve the quality of the care they provide.

11. Include special needs populations. Right now too much of the access to these forms of medicine is limited to those who can provide for it out-of-pocket. That means the underserved, the poor and uninsured, those with special health problems, like HIV and AIDS, the elderly and such, do not have access to the services which can be of benefit to them.

12. The reimbursement system needs careful reconsideration. The problem is right now the reimbursement system pays for disease treatment and yet we need to develop a system that pays for health promotion. Right now even when health promotion is covered, if you look at the codes you get paid less per minute of time to provide prevention services than for diagnostic and therapeutic services. This is ridiculous, we need to change that. We also, as we go through the reimbursement system we must fully engage the payers net process. We can't simply impose a process on it from the outside.

13. There is a critical need for accurate information for the public and professionals. We need to develop content databases that validate intervention and ethicacy and safety of interventions, systems of healing and particular therapies. We have a good process for adverse events reporting and monitoring and we need to establish systems to disseminate information about these therapies so that practitioners and the public will know what is safe and what is appropriate.

14. We have a critical need for natural product quality assurance programs, either public or private. While most of the products out there are safe, reliable, and effective, too many are not safe, reliable, and effective. And we need to develop methodologies to ensure both practitioners and the public have good quality products that are safe for the public.

So finally, ultimately good health comes from personal decisions which means it's absolutely imperative that public health be fully engaged in the new health care . . . as we develop it. As you know, we spend 98 percent of our health care dollars on interventions and only two percent on public health. And yet the benefits derived from public health far exceed those of interventions. We must engage public health fully.

So at the end of these two days I think you will see the value of collaboration, recognize the importance of standards and accountability, and see that this remarkable phenomenon in the Northwest is not only about integration or leveling the playing field, it is about a shared vision to create a true health care system and not be limited by our current disease stricken system. Thank you.

GORDON: Maggi Fimia. Maggi is it? Sorry, please.

FIMIA: Good morning Commissioners, members of the audience, my name is Maggi Fimia. I'm one of the County Council members from the King County Council and am delighted, absolutely delighted and honored that you are all here this morning. One of my favorite expressions in the whole world is "believe everything or doubt everything, there's two ways to slide through life. Believe everything or doubt everything, both ways keep us from thinking." We are at a point in this world, I believe, in this region and this country where we are recognizing that we can no longer just believe everything or doubt everything. That the decrease in the quality of life and the escalating costs of criminal justice, transportation, environment, and health care are forcing us to start looking and listening and sharing with each other as to what is best and not to continue to doubt everything or believe everything. We need to let go of some of our beliefs and we need to hold on and adopt new ones. And through that deliberation that you are engaging in at a national level and that we are engaging in at a local level of sharing with each other we will come to recognize all those grey areas of great wisdom that we have collectively so that we can deliver better health care, more sustainable health care at a much lower cost, now and in the future. And I think that's what this exercise is going to be all about.

I got a phone call a few weeks ago from the appointee that I appointed to the Harborview Board of Trustees. Harborview is our regional hospital here, emergency trauma hospital, that we're very very proud of. And we just approved a ballot measure to be able to do retrofitting for seismic retrofitting and to increase the number of beds. I got a phone call from my appointee on that Harborview Trustee Board asking me to please support putting this on the ballot, which of course I did. My appointee is a naturopathic physician. That never would have happened five years ago, ten years ago, twenty years ago. And here this naturopathic physician was calling me to ask me to please support this incredibly important traditionally medical establishment.

I also got a call from a physician, a medical doctor, who is engaged in doing research on the importance of activity and nutrition and social interaction for seniors. He's engaged in some very significant research. He used to be the medical director at Harborview and now is doing this work with seniors in conjunction with senior centers to demonstrate that importance. Again, never would have happened five, ten, twenty years ago.

I'm a former registered nurse, former Lamaze teacher, formerly married to a naturopath who has now defected and become a medical doctor. And when we set up practice 25 years ago in Hood River, him as a naturopath, me as a child birth educator, no one knew what naturopathy was. The American Cancer Society and the medical societies were all absolutely discounting the importance of nutrition, for instance. They discounted that had anything to do with cancer, diabetes, heart disease. We were just shouting in the wind. Now that's established fact.

There is much work to be done. I think we need to celebrate during these next two days what has been accomplished and then outline what we can do together in the future. I welcome you and I welcome that discussion.

GORDON: Thank you all very much. We appreciate it. Will you be coming back to talk later, Joe? I'm just curious, before, if anyone wants to ask Joe Pizzorno a question or two, especially the new Commissioners who didn't have a chance to speak with him in Washington. Any questions at this point? Okay, we'll catch you later. Thanks so much, Joe.

Would the next panel please come up. It will be Richard Lyons, Dorothy Wong, Gail Zimmerman, Henry Ziegler, and Kathy Abascal. If I mispronounce you can correct me. I'm always interested in how to say it right. And what we'll do is each person will speak in turn in the order that's listed in the program. I think that will make it easiest. So just keep of track of it for yourselves. And remember, we'll have a chance to ask questions after all of the panelists have spoken. Richard Lyons please.

Speakers

LYONS: I'm Dick Lyons. I work for the Department of Health and Human Services as the Regional Health Administrator and my boss is Dr. Dick Kelley who just gave a greeting. It's a pleasure to be here. We're very excited to have all of you here and you're going to hear some exciting things from our colleagues in the next two days.

I'd like to give you just a little perspective of this region, which is the states of Alaska, Idaho, Oregon, and Washington. It comprises about 22 percent of the surface area of the whole country. In that surface area we have distributed about three percent of the U.S. population, so we are a rural state. We have tremendous examples of poverty and underserved communities in this region. It's a tremendous importance to us. Particularly the Native American population, which we have approximately 20 percent of the total Native American population in our region in almost half of the federally recognized tribes. So we're very interested in that particular underserved population. And also in the immigrant population, which is ever growing in our communities. And many of these populations are very interested in CAM services and indeed the general interest in CAM services has increased in our region very rapidly over the past few years. So I think we have a number of unique things about our region.

We also have a number of unique activities going on here which you are already aware of from hearing Dr. Pizzorno give you his long list of things. And many of those are going on right here in this community. I'd like to make a couple comments about the training programs and give you an idea of the number of licensed individuals practicing CAM services in our region. I think it's fairly incredible that we have virtually all of the training programs for the CAM professions here in our region. One school for chiropractors in Portland and we have about 3,700 licensed chiropractors in our region. Two of the three naturopathic schools are here in our region. And we have approximately 900 practitioners licensed now. We have four licensed midwifery schools and approximately 140 current licensed practitioners. We have five acupuncture and Oriental medicine training programs which have provided a large part of the graduates that are now licensed approximately 1,100 in our region. And finally massage therapy training programs, we have about 12,000 licensed massage therapists in our region. So we have a lot of practitioners.

The reimbursement issue is very important. We have some incredibly important activities, both in the state of Washington, which Lori has already mentioned, a mandated program. We have a nonmandated but fairly successful program for reimbursement by the major insurers in Oregon. I think a really exciting thing in this state we have the first state that has designated service for CAM providers, particularly naturopaths and licensed midwives to practice in underserved communities and extend the loan repayment service to them. Which I think is a good model for us to consider for the rest of the nation.

The research components are strong here. Both our major allopathic medical centers in Portland and in Seattle have working relationships with the CAM schools in their communities. They need to be strengthened but they're there. They're embryonic and ready to grow. And of course Bastire has its own research program.

Washington's tremendous gains in dealing with issues relating to CAM providers has been amplified by Maggi and also by Joe Pizzorno and I think I don't need to mention that any more, but I think it's exciting that there are many involvements of CAM providers in this community.

I'd like to conclude with pointing out some of my feelings about what we need to do. I think we need to develop a list of critical community assets that support the development of CAM practices, and we have many of those in our community. Joe has mentioned a lot of them, and I've referred to a few of them. I think we need to perfect that list and then find ways to strengthen and develop those assets in communities so that CAM activities can proceed effectively.

And I mentioned extending the federal laws to include loan repayment for some of the CAM professions in underserved communities. I think that would do a lot of good, particularly for the younger practitioners coming out, of which we obviously have a lot in our region.

And finally I'd like . . . also support the notion that Dick Kelley gave about focusing activities in CAM on Healthy People 2010 because CAM providers often deal with lifestyle and behavioral issues which are the crux of Healthy People 2010. And I think we must learn how to reward and reimburse practitioners, both CAM and allopathic physicians, in the service of health and human behaviors and changing lifestyles. It's critical. It's the new wave of public health and it's something we have to do with great enthusiasm. Thanks a lot.

GORDON: Thank you very much.

The first, complementary and alternative medicine is a very common practice among Asian and Pacific islander immigrants. Given the access failure to mainstream medical care, including lack of insurance, need for interpretation, limited knowledge about the medical care system, immigrants will often choose the more costly familiar ethnic health care practice such as acupuncture, herbs, massage, cupping, corn rubbing, traditional healers, etc. Research needs to be funded to accept the practice of these traditional methods, particularly looking at any interaction with concurrent allopathic medicine as well as the potential hazards and benefit of the traditional practices themselves.

Second, acupuncture and herbal medicine research cannot be taken out of context from their cultural background. Much of current research is done under the gold standard of randomized trial. This means that treatment must be standardized in order to compare treatment options. But traditional acupuncture and herbal treatment cannot be standardized for neck pain, for example. Since the treatment would be individualized according to specific imbalances in energy flow of the different body meridians, traditional Chinese medicine would involve a different treatment for each individual presented with the same problem. Unfortunately, much of current research being funded does not allow for these traditional means of diagnosis and treatment . . . standardize the therapy. Other research methodology will need to be developed to accept these therapies in their cultural context.

Finally, complementary and alternative medicines seem to be of benefit for the wide range of conditions that are not well treated by allopathic medicine. Chronic neck and back pain, neuropathic or nerve related pains, chronic tendinitis or irritation in tendons, such as tennis elbow, pregnancy related nausea and vomiting are some of these conditions. These conditions are not easily or successfully managed with medication or the side effects of medication have significant complications in themselves. Access to complementary and alternative medicine needs to be available and consistent. In California, for instance, work related injuries and Medicaid patients have coverage for complementary and alternative medicine. But in Washington state these same patients are not covered for these services.

Traditional Chinese medicine could be similarly covered from state to state. Practical guidelines for common ailments could include and integrate complementary and alternative medicine with allopathic medicine, particularly for these chronic conditions. Reimbursement for these services could uniformly be covered following these practice guidelines. It would allow for provider and patient option in managing of these conditions. Thank you.

GORDON: Thank you very much. Gail Zimmerman, are you going to speak at this point or not? Okay. Henry Ziegler.

ZIEGLER: Good morning Commissioners. I'm Henry Ziegler, a public health and internal medicine physician. I'm proud to be here. My entire career has been underserved care and that's my passion. Internationally for many years and inner city Cleveland and in the last number of years as head of prevention at the Public Health Department here, Seattle, King County. I'm currently the Community Based Planner for the Lumi Indian Nation of which I am very proud. And I also teach at Bastyr in public health and do research there and do teaching at the University of Washington School of Public Health.

From that bases then, the following recommendations. In order to successfully address the health disparities and the needs of our poor and underserved we need all of the resources we can get. That includes our CAM professionals who are now not available in many cases. Showing of hands from my Bastyr medical students, over half were interested in underserved care. When I've done the same thing at University of Washington in previous, at Case Western, I run 20 to 30 percent. So there's more interest.

How do we get them involved? Well, first we have to make it feasible for them to do it. And that's called loan repayment so they can work in underserved areas. Second, we have to have Medicaid and Medicare coverage so they can continue to work there. Then we need to do research to look at their roles in primary care in underserved areas because if we don't know how they fit it's very difficult to get anybody to gamble to put them in the fit.

Shifting to the broader issues and what Joe was saying about collaboration, partnership is critical. We're very excited about a partnership we're developing with pulls together Northwest Indian College, Bastyr University, Region X HHS and other partners, nonconventional partners if you will, we're trying to break the bonds because we want the representatives of the underserved communities working with the CAM providers and with ourselves to make things work.

In addition to those kind of pieces we need to not simply train the conventional practitioners in CAM approaches, but use the CAM professionals with their whole paradigm shift, their whole looking at things from a different vantage point. We need to train our CAM providers in public health. They already have a holistic wellness approach. What they lack is the sense of the community as their patient, in addition to the individual and the family. As you do that they become fabulous public health practitioners. And finally, our minority communities are comfortable, as you're already hearing with CAM, because they partner well, and that partnership needs to be led by those committees themselves, not by us. Thank you very much.

GORDON: Thank you very much. Kathy Abascal.

ABASCAL: Hi, I'm Kathy Abascal, the Executive Director of the Botanical Medicine Academy. The BMA was formed on the premise that all health care professionals who use Western herbal medicines should work together. And the BMA is an umbrella organization that brings together all of the health care practitioners that use these botanicals, that is, M.D.s, N.D.s, osteopaths, midwives, pharmacists, nurse practitioners, herbalists and others.

Our mission is to enable consumers, governmental agencies, insurers, and other interested parties to be able to identify practitioners who are expert in the use of Western plant medicines. The BMA is urging this Commission to recommend a policy that supports and helps fund the creation of a voluntary national standard, perhaps through a national clearing house, for the practice of botanical medicine, a standard that cuts across professional categories and maintains the focus on identifying the quality of knowledge that practitioners offer the public.

Health care under our legal system is primarily the concern of the individual 50 states. However, this model presents unusual problems in CAM because so many different types of professionals use herbs. How can we accomplish reliability if standards differ, not only state to state, but from profession to profession? And how do we achieve a standard for Western herbal practice that also allows traditional healers to continue their practices? The BMA believes the public can achieve this reliable standard through a voluntary exam that measures only knowledge of the use of Western medicinal plants. After all, consumers should be able to assume that all practitioners prescribing herbs have the same degree of knowledge about the plants they use.

The BMA, working with the American Herbalist Guild, will this fall offer the first exam that measures that knowledge. The first exam will be directed to advanced clinical practitioners, but we will soon be offering a basic exam to practitioners entering the field. These exams will cover usage, dosage, side effects, interactions with other medications, quality of products and other such topics. The resulting certification will empower consumers to access quality information about the herbs they want to use. And it will set a bench mark that schools can model their educational programs to and give the government a single standard to monitor.

A policy decision to support and fund a single voluntary standard for all professionals will help the public enjoy the benefits that alternative medicine has to offer. Thank you.

GORDON: Thank you very much. I think the way we'll do questions is we'll start from one end and move on up. It's easier and then each in turn, if you'd like to ask questions please feel free.

Questions from Commissioners

MAN: I have a question for Dr. Lyons. Dr. Kelley spoke about health disparities and it has been a theme that has come up and Ms. Wong has some data here on utilization of services. Has your region access to any systematic look at utilization with a specific focus on health disparities regarding CAM therapies in the region?

LYONS: Yes, we have access to a lot of information about that through our associations with the CAM schools. And actually my office has funded two special projects to look into the health disparity issue in underserved populations. So those activities are at Bastyr so we're very closely connected to it. And one thing that I probably didn't mention in my testimony is that I think the crucial thing that we have in this community in terms of an asset is a close working relationship. We've met with each other for a number of years. Some of that is going to be brought out in future testimony, and we're connected. We talk together, we have fun together and we're becoming close associates just in the last few years. I think in like about three or four years. And so we exchange information a lot and we collect sources of information relevant to extending the services into the underserved communities.

MAN: Regarding you mentioned that massage therapies, you have 1,200 in this state. How do you get registration? For instance, what is training program to be registered if it's not a license?

MAN: I'm sorry, Doctor, I'm not the expert on that. I think Lori Bielinski would be because she's a massage therapist and works in the insurance commissioner's office so I really can't answer that question.

WOMAN: This is actually to Dr. Ziegler. The data that you have been collecting on utilization and poverty in the underinsured or underserved, how long have you been looking at that in a collaborative way? One year? Two years? Three years? Is this a recent phenomenon.

ZIEGLER: We've actually just started the process. And what we're doing is an apprec(sp?) inquiry survey of Bastyr and Northwest Indian College. If you're familiar with apprec(sp?) inquiry you look at what's working, why it's working, and a vision of the future. And it's much more powerful than looking at the problems and trying to build from there. And so we're doing that in terms of the public health activities within Bastyr, within Northwest Indian College and then looking at how we can create through that combination a stronger career ladder for our Indian community, as well as stronger public health entities within both Bastyr and Northwest Indian College.

WOMAN: Thank you.

GUTIERREZ: After 37 years I didn't know there was a Northwest Indian College, so that's helpful information.

GORDON: Effie.

CHOW: I appreciate all the deliveries very much. Being in Washington the Northwest is in a leading field of the development that we are looking for models in which we could perhaps look at and pattern and I would like to ask if it's possible for you, Dr. Lyons, and the others, to present a more detail of how to. How did you reach this progressive state and perhaps be helpful to us as Commissioners in a more detailed forum. I really appreciate the creativity that has happened here.

LYONS: I'm sure most of us would be very eager to do that. We enjoy having those kinds of discussions and sharing information and we would entertain that. I think that, I like the concept of assets which I mentioned, and I think there's probably a critical number and type of assets that need to be in a community to make a really good environment for the advancement of CAM issues. And I think we just happen to have a lot of them here. And we've enumerated some of those. And I think getting a good list and figuring out which ones are the most important assets is a real critical step. And we'd love to work with someone about that.

CHOW: Perhaps we share some of those secrets.

WOMAN: I appreciated all the comments as well. I have a question for Dr. Lyons and Dr. Ziegler. Coming from New Mexico, I'm also from a very large underserved state and as a physician have worked in those areas. I am curious that naturopathic physicians and licensed midwives are being considered now, or are going into underserved areas and are being able to extend loan repayment or having loan repayment done, which I think is fantastic and a real step forward. But those are models that actually work within more of a Western paradigm, so they're easier to adopt. But I didn't hear anything about chiropractors or acupuncturists which also could benefit from that. I just wondered where that was at or if that's something that is being considered for underserved areas as well?

MAN: I'm sure that it is, and there are experts here that are going to give testimony on that loan repayment program that can answer the question much better. So I think we have probably refer to that. But I think they stick the first categories of naturopathy and licensed midwifery just because those were easier for them to deal with at the time and to get malpractice coverage and things like that. I'm sure their intention is to expand that. And I think it would be a good model to use in other parts of the country.

MAN: I concur, that's what my understanding is as well. This is the beginning of the wave, not the whole thing.

MAN: On botanical medicines, may I ask, is the process of establishing authority within the academy of what dosages, what clinicals, all of that research? Is it possible for you to establish an authority of where that standard should be? And secondly, do you envision that we would be able to project that same model into a regulatory world?

ABASCAL: In the exam context it's a bit easier because where there are disputes sometimes it's enough for the practitioners to know the different points of view and to explain them to their clients. And it's easier to test within a more open ended context of what might be appropriate, what the risks are, the benefits are. So we can test a knowledge base I think much more easily than we can actually create a hard standard that comes about when you try and legislate. And I think that is part of the reason a voluntary peer created and peer maintained system certainly initially provides such great benefit. Because we have all of the various professionals coming together, the experts in the field, finally articulating very specifically what we know, what we need to know, how we should test it and how we should educate it. And we're finding that just creating the exam has provided us with substantial knowledge that we were lacking previously as we tried to design educational programs. So it's a very interesting process.

GORDON: I have a question for Dr. Ziegler. I'm wondering if the guidelines for training CAM practitioners in public health, if you have those guidelines now and if we could have a copy of them?

ZIEGLER: I don't with me, but I'm sure we can get you the guidelines. And they vary again, the comment earlier about variety of CAM professions, you have a variety of CAM professions and so you're going to have different guidelines and certainly.

GORDON: I think this would be very helpful. What you're raising is a whole issue that would be very helpful for us to learn more about and the wonderful thing, as we listen to you is that so many of you and so many, I'm sure, of the people who will be speaking to us today have already taken the kinds of steps locally, and we really need your experience to help us shape national recommendations. So I hope that we'll also have that detailed information about the loan repayment forgiveness plan as well. That will be very helpful to us. Thank you all very much.

Speakers

GORDON: Next panel is Lori Bielinski, Kent Pullen, Alonzo Plough, and I'm still going to say, is it Maggi or Maggi? Maggi. I have a friend named Maggo, so, is your last name Italian?

FIMIA: Right.

GORDON: Right. Okay. That's my confusion. I'll surrender. First will be Lori Bielinski please.

BIELINSKI: Good morning. My name is Lori Bielinski and I'm a licensed massage therapist and a senior health care policy analyst at the Office of the Insurance Commissioner. In 1993 health care reform legislation was enacted in Washington that assured consumers could buy health insurance even if they were sick or changed jobs. Simultaneously, provider groups pursued inclusion of all licensed health care providers for insurance reimbursement within their respective practice scopes. To preserve the insurer's ability to select competent providers, the final legislation settled on the term every category without mandating inclusion of every individual practitioner. Subsequent revisions preserved these reforms and the Office of the Insurance Commissioner promulgated rules to implement that intent. An unusual footnote is that of the many sections of these reforms, this is one of the few portions of the law that remains. It has stood challenges in both the democratic and republican legislative majority, it has generated the most controversy, and is the most popular, as well as having been upheld by the U.S. Supreme Court.

There are specific criteria that must be met. The CAM professions must be regulated by the Department of Health with licensure or certification. The scope of practice must allow the provider to treat the condition that the patient presents. The provider must be contracted to be eligible for reimbursement. And finally, the patient must have benefits covering a condition that is within the scope of practice of the chosen practitioner. This is not an any willing provider law, nor is it a mandated benefit law. It allows consumers access to a choice of the provider who will treat the condition in which they are seeking care. Carriers have the right to credential providers as long as the standards are consistent with those established by the Department of Health. Carriers must not set network adequacy requirements, excuse me, they must set network adequacy requirements based on the number of covered lives in a jurisdiction where they are responsible for providing coverage. Carriers have the right to set the coverage limits, including services of CAM providers. The OIC has established rules that state these limits may not be unreasonable and may not be set by provider type but can be set by covered services. And the carrier may not exclude a particular category of provider altogether, nor can it cover certain provider types only by a separately priced optional benefit.

Thus, it became very important to clarify to insurers, providers, and the public that the law relates to all regulated health professions and not just those considered those alternative. Additionally, the law does not mandate a benefit for anyone. It allows patients access to the provider of their choice for covered conditions.

The initial environment impacted by the threat of ongoing litigation. After many discussions, parties agreed how to establish a joint work group and hire outside facilitation. It was agreed that the OIC would convene clinicians from the carriers and the professional associations to focus on clinical issues. The full work group agreed that all decisions would be made by a planning committee made up of a smaller group of the whole to assure that all parties were represented in the decision making process. Participants included outside facilitation, CAM professional association representatives from acupuncture, chiropractic, dietician, massage therapy, licensed midwives, and naturopathic physicians, medical directors from carriers and CAM provider networks also.

In the second and third year we expanded the work group to include primary care physician organizations, educational institutions that train the CAM professions and the State Department of Labor and Industry's Our Workers' Compensation Program. The group's '97 work was spent developing trust, building working relationships and establishing agenda. The '98 agenda was very aggressive, including coverage decisions, technology assessment, medical necessity, and most significant was the training of CAM practice guidelines. The 1999 clinician work group activities were focused on the known integrated clinics and additional training on practice guideline development.

The most important deliverables were the final report which you've been handed out, and draft seed algorithms for at least one condition for each profession. They are in appendix I of the report with the stipulation that they are drafts and have not yet been tested, implemented, refined, or subjected to peer review. Each profession has been encouraged to continue develop algorithms using the peer review process.

In this process we learned that developing trust and understanding of each other's language was critical to a positive outcome. Continuous representation assured participants that everyone was invested in the process and could build on those relationships. We believe that the next step should include research, not just of clinical efficacy, but of true utilization of CAM services in conjunction with or in replacement of normally covered conventional care. Case management considerations should be addressed, and education of all entities is the most important byproduct of such an effort.

Finally, a national forum of this caliber or multiple forums in several locations can break down barriers to trust and understanding of CAM services and eliminate divisive action by people or groups that are operating in a noneducated environment. This is a consumer demand and we as policymakers have the responsibility to move the decision making into well rounded, deliberate discussions about cost, access, and outcomes.

GORDON: Thank you very much. The next speaker will be Kent Pullen.

PULLEN: Since I will be talking about the role of King County in promoting natural medicine, I should begin by defining natural medicine. Natural medicine refers to healing through a better lifestyle and with the help of natural substances. We seek to correct deficiencies by putting into the bodies substances that belong there, such as vitamins, minerals, amino acids, enzymes, hormones, and digestive aids. And we seek to take out of the body bad things that don't belong there, such as toxins and allergens. Natural healing begins with a good diet. It includes eating natural whole foods, not processed or refined. It includes avoiding chemically altered foods, such as trans fat and avoiding additives, such as food coloring and chemical preservatives. It includes the use of therapies like chiropractic, acupuncture, and homeopathy which help the body to heal itself.

In 1994 I was curious to see if the county could promote better health care. I began by getting advice from a number of local leaders, Merrily Manthey, Dr. Joe Pizzarno, Dr. Jeffrey Bland and Dr. Jonathan Wright. I think you'll be hearing from most of this talented group, although at the present Dr. Wright is in Asia. But he did leave a videotape for your viewing.

I then consulted with my fellow elected officials and found that 11 of the 13 members of the County Council were already using natural medicine and were quite happy with the results. Encouraged by this support, I introduced a motion calling for the creation of a natural medicine clinic. The motion was adopted unanimously and we began getting a lot of help from a variety of sources. We were able to secure funding to open the clinic. Tom Trompeter of the Community Health Centers of King County agreed to manage the clinic and did a superb job. Bastyr University provided support in many ways. The staff were wonderfully cooperative and proved that conventional and alternative practitioners could work side by side in harmony. But most important, the natural medicine clinic was a huge success and the patients loved it. We received testimonials from some patients who said they've been trying for 20 years to solve their medical problems without success, until they were made well at the natural medicine clinic.

I'll conclude by noting that we have since made additional progress by incorporating natural medicine into health benefits for employees and we've begun planning to integrate natural medicine with conventional medicine. Why have we been so successful? I think it's because the Seattle area is quite progressive and because we have so many outstanding leaders here, such as the people I previously mentioned. We look forward to further progress and greatly appreciate your interest. Thank you very much.

GORDON: Thank you. Alonzo Plough.

PLOUGH: Thank you. My name is Alonzo Plough. I am the director and health officer of the Seattle King County Department of Public Health, Associate Professor of Health Services in the School of Public Health University of Washington.

I am very very pleased here to talk about in general, but what have to be the local underpinnings of partnership in order to transform local health systems so that complementary medicine, public health, and primary care can develop integrated models. And I'll speak in particular about our role in the King County Natural Medicine Clinic that Mr. Pullen identified. But I want to particularly emphasize the importance of the integration of public health practice and complementary alternative medicine as a transformational principle for the U.S. health care system in general.

When I came to Seattle and King County from being Commissioner of Public Health in Boston and in my confirmation hearings with the King County Council, I was surprised by a persistent line of questioning from members who are sitting with me right now. And those questions were about my proclivities around complementary and alternative medicine, how did I see this fitting into the role of the health department I would be taking over. An unusual set of questions speaking to an unusual practice environment. I was very fortunate, I never knew how fortunate it was, that I had played a role in developing the first acupuncture clinic in a teaching hospital in Boston at Boston City Hospital and used that example at least to say that I've had some experience and wanted to get more in doing that. I hope that played an important role in my being confirmed. But I realized immediately that I was in a very different practice environment with lots of different possibilities for the promotion of health and well being in the region. And the kinds of leadership and local leadership that the King County Council demonstrated through their natural medicine motion which Mr. Pullen just described and I will not, has really set the tone for the work that my department has been able to do over the last six years. And allowed us to develop a practical and grounded approach to, again, recognizing the real importance of public health in complementary and alternative medicine as the main catalytic partners in increasing prevention and well being focus for the entire U.S. health care system.

So again, a guiding local vision by elected officials was certainly key to the changes we've seen in our region and it was very exciting to me today that four members of the King County Board of Health are with you today.

Our King County Natural Medicine Clinic, of which you'll hear more about from some of the folks who are working with that on the ground later, was a partnership. We called it a three legged stool, between public health, community based primary care, and CAM. And I think those three legs are really what made this very exciting. It was a partnership between the Public Health Department, Bastyr University, Community Health Centers of King County, with some evaluation and statistical work done from the University of Washington. I think that the ability of these institutions to collaborate around this activity was really important, and I think it took particular strength that we have in our region with Bastyr, Northwest School of Acupuncture and Oriental Medicine, the International Foundation of Homeopathy, many strong partners in doing this. What makes this partnership work I think was the respect of each of us of our different traditions. And I think that was a hallmark of the startup of the King County Natural Medicine Clinic. And I'll just note a few things that I think were particularly important.

This clinic was the first publicly funded integrative clinic that integrated alternative medicine, public health, and primary care. It was the first clinic to partner with a local public health department.

GORDON: We're on such a tight schedule. Could you submit those to us.

PLOUGH: I will.

GORDON: Okay. Thank you. I'm sorry to interrupt.

PLOUGH: Submit the?

GORDON: The characteristics to us.

PLOUGH: Fine. Should I just go on?

GORDON: No. If you could do it in 30 seconds, yes.

PLOUGH: Then I'll just conclude then. Again, I think that what we've seen in the clinic is a focus on prevention, a focus on the integration of the two traditions, and I think that's really key to transforming health systems.

GORDON: Thank you. I'm sorry we have to be tough with the time. We very much want to review the written material as well. So if you can't get it all into a speech, know that we're going to be taking a look at it. Maggi Fimia please.

FIMIA: Maggi Fimia, King County Council and I spoke before. I just wanted to touch on the potential role of government here, both federal, state, regional, and local government and what I see as our role.

The public in this region, and I can't speak for the others, but my sense is probably other regions as well, are way ahead of their governments in the establishment, in recognizing that there is a continuum of health care, it's not an either or. They want access to all different forms of health care, but they want it to be health care that actually works and is effective. The need is tremendous for us to address this issue now. We are working on our King County budget, for instance, right now and have found out that in 1998 our per employee health care cost was $480 a month per employee. Two thousand and one, the budget that we're looking at now it's up to $654 per employee. That's a 36 percent increase over just those three years, and we have 13,000 employees. We're just one government. This is happening to businesses and all governments. Clearly we want to make sure that with these tremendous investments in health care we are getting an equivalent or greater benefit in seeing increased wellness, not just attacking illness, but increasing wellness.

So government's role I think is to provide the forum to allow the different modalities to come together with both providers and the consumers of health care to set the tone for those forums so that people are willing and able to listen to each other and we know personally that we don't listen very well or learn very well if somebody is yelling at us or telling us that we're wrong and that what we've been doing for the last 30 years is incorrect. It doesn't facilitate change and tolerance. So government's role, if we're going to take one, is to be the referees and to set the tone that this will be a forum for increasing tolerance and listening to each other and recognizing that there's great value to what everyone is bringing to the table.

And to that end, we have set out a process here in King County called King County 2010 Integrated Medicine. Our goal for that process is to create an actual strategic planning document at the end of the process which would do three things.

First, celebrate what we've all accomplished, all modalities and all disciplines, over the last 30 years in terms of integration and promotion of wellness. And then to map out where we are now. Take an inventory. The town hall meeting has sped that process up and we are just absolutely very amazed and proud of ourselves for the list of speakers that are coming today, which is basically the beginnings of that inventory of what's happening in the region. And third to collectively decide on five to six goals that we can accomplish much better if we pull together and put them in a strategic planning document, identify who should take the leads on those different goals so that by 2010 we can look back and say, look what we accomplished together so much better, so much more collaboratively and effectively than if we had tired to do these things by ourselves. And they would be in the areas of research, of teaching, of cross training, of actual delivery of health care, and in insurance. Those seem to be the broad areas where people seem to think we need to have the most work together. Thank you.

Questions from Commissioners

GORDON: Thank you all very much. We'll begin with questions from the other end, with Tom Chappell. Come closer to the mike. Speaking of the mike, can people in the back hear all right? Yes? Okay, great.

CHAPPELL: Maggi, I think I may have missed the nature of the collaboration you were speaking of when you talked about the five or six goals, things, you have something working now.

FIMIA: Yes.

CHAPPELL: I was just wondering, did you plan on extending that collaboration?

FIMIA: We have been working for two and a half years. We started with a small group of people that we knew on our radar screen, pulled them together from all the different practitioners and insurance commissioners, from the government research education and implementation and said, first, do you want to do this? Is this a good idea? The answer was yes. The County has taken the lead to do the staffing for this, along with Bastyr and some other institutions. It's been great. And then we said, okay, who is the next circle of folks who should come to the table? Who else do you know about that should come to the table, look at what we've produced so far as far as accomplishments and potential goals. We've done that and had 50 people instead of 20 people. We are working on the next round of making that a 200 person, so that there are actually more consumers of health care at that table, bringing them the draft information and documentation that we have already and saying, are we getting this right? What else should be included in on recognizing the accomplishments, mapping out where we are, and are these goals ones that you could concur with and should they be more refined as far as goals? How do we measure our success? So yes.

And then to actually go after funding collectively so that we're not at cross purposes and that we have money to actually implement this strategic plan. And set up some sort of institutionalized or recognized body where all these different groups can be coming together on a regular basis and have something formalized as far as structure so that we can update the plan as necessary.

GORDON: What we'll do is just move down the line. If you don't have a question, just pass and we'll go through.

WOMAN: Sure. Dr. Plough, something that we hear over and over again is about research based medicine. And this is in some parts of the country the excuse that's been used not to have integrative centers because some of the modalities lack research or evidence based medicine. It seems that your clinic is an ideal place to do outcome studies, clinical audits, case series. Is that being aggressively done at your clinic so that that research can become available so that we can actually look at therapies and if they save money, if they work for what, etc.?

PLOUGH: We've begun some of that in the initial evaluation of the clinic. But I think only just the tip of the iceberg of those kind of studies. I do agree that it is a site where, if those research funds could be acquired, those kinds of evidence based questions could be addressed.

WOMAN: Funding. Money.

PLOUGH: Funding. Exactly. Those are very expensive. To do the kind of evaluation we would have liked to have done, to look at those outcome measures would have been multiples of the money that we had invested from the County to start up the clinic. So we were very much in need of those research dollars.

WOMAN: Mine deals with money too. And regarding the insurance, we're always frustrated with treatments being paid and there is no effect. And then when there is treatment that is effective there is no payment and people have to pay out of their own pocket.

White House Commission On Complementary And
Alternative Medicine Policy

October 30, 2000
10:40-11:40 am

WONG: My name is Dorothy Wong and I'm the Executive Director of the International Community Health Services, a community health center that primarily serves the limited English speaking Asian and Pacific islander immigrant population in Seattle and King County. Alongside Allopathic Western Primary Medical and Dental Care we provide traditional Chinese medicine . . . services which include acupuncture . . . herbs and cupping. I have three main issues I would like to bring to the Commission's attention.

The first, complementary and alternative medicine is a very common practice among Asian and Pacific islander immigrants. Given the access failure to mainstream medical care, including lack of insurance, need for interpretation, limited knowledge about the medical care system, immigrants will often choose the more costly familiar ethnic health care practice such as acupuncture, herbs, massage, cupping, corn rubbing, traditional healers, etc. Research needs to be funded to accept the practice of these traditional methods, particularly looking at any interaction with concurrent allopathic medicine as well as the potential hazards and benefit of the traditional practices themselves.

Second, acupuncture and herbal medicine research cannot be taken out of context from their cultural background. Much of current research is done under the gold standard of randomized trial. This means that treatment must be standardized in order to compare treatment options. But traditional acupuncture and herbal treatment cannot be standardized for neck pain, for example. Since the treatment would be individualized according to specific imbalances in energy flow of the different body meridians, traditional Chinese medicine would involve a different treatment for each individual presented with the same problem. Unfortunately, much of current research being funded does not allow for these traditional means of diagnosis and treatment . . . standardize the therapy. Other research methodology will need to be developed to accept these therapies in their cultural context.

Finally, complementary and alternative medicines seem to be of benefit for the wide range of conditions that are not well treated by allopathic medicine. Chronic neck and back pain, neuropathic or nerve related pains, chronic tendinitis or irritation in tendons, such as tennis elbow, pregnancy related nausea and vomiting are some of these conditions. These conditions are not easily or successfully managed with medication or the side effects of medication have significant complications in themselves. Access to complementary and alternative medicine needs to be available and consistent. In California, for instance, work related injuries and Medicaid patients have coverage for complementary and alternative medicine. But in Washington state these same patients are not covered for these services.

Traditional Chinese medicine could be similarly covered from state to state. Practical guidelines for common ailments could include and integrate complementary and alternative medicine with allopathic medicine, particularly for these chronic conditions. Reimbursement for these services could uniformly be covered following these practice guidelines. It would allow for provider and patient option in managing of these conditions. Thank you.

GORDON: Thank you very much. Gail Zimmerman, are you going to speak at this point or not? Okay. Henry Ziegler.

ZIEGLER: Good morning Commissioners. I'm Henry Ziegler, a public health and internal medicine physician. I'm proud to be here. My entire career has been underserved care and that's my passion. Internationally for many years and inner city Cleveland and in the last number of years as head of prevention at the Public Health Department here, Seattle, King County. I'm currently the Community Based Planner for the Lumi Indian Nation of which I am very proud. And I also teach at Bastyr in public health and do research there and do teaching at the University of Washington School of Public Health.

From that bases then, the following recommendations. In order to successfully address the health disparities and the needs of our poor and underserved we need all of the resources we can get. That includes our CAM professionals who are now not available in many cases. Showing of hands from my Bastyr medical students, over half were interested in underserved care. When I've done the same thing at University of Washington in previous, at Case Western, I run 20 to 30 percent. So there's more interest.

How do we get them involved? Well, first we have to make it feasible for them to do it. And that's called loan repayment so they can work in underserved areas. Second, we have to have Medicaid and Medicare coverage so they can continue to work there. Then we need to do research to look at their roles in primary care in underserved areas because if we don't know how they fit it's very difficult to get anybody to gamble to put them in the fit.

Shifting to the broader issues and what Joe was saying about collaboration, partnership is critical. We're very excited about a partnership we're developing with pulls together Northwest Indian College, Bastyr University, Region X HHS and other partners, nonconventional partners if you will, we're trying to break the bonds because we want the representatives of the underserved communities working with the CAM providers and with ourselves to make things work.

In addition to those kind of pieces we need to not simply train the conventional practitioners in CAM approaches, but use the CAM professionals with their whole paradigm shift, their whole looking at things from a different vantage point. We need to train our CAM providers in public health. They already have a holistic wellness approach. What they lack is the sense of the community as their patient, in addition to the individual and the family. As you do that they become fabulous public health practitioners. And finally, our minority communities are comfortable, as you're already hearing with CAM, because they partner well, and that partnership needs to be led by those committees themselves, not by us. Thank you very much.

GORDON: Thank you very much. Kathy Abascal.

ABASCAL: Hi, I'm Kathy Abascal, the Executive Director of the Botanical Medicine Academy. The BMA was formed on the premise that all health care professionals who use Western herbal medicines should work together. And the BMA is an umbrella organization that brings together all of the health care practitioners that use these botanicals, that is, M.D.s, N.D.s, osteopaths, midwives, pharmacists, nurse practitioners, herbalists and others.

Our mission is to enable consumers, governmental agencies, insurers, and other interested parties to be able to identify practitioners who are expert in the use of Western plant medicines. The BMA is urging this Commission to recommend a policy that supports and helps fund the creation of a voluntary national standard, perhaps through a national clearing house, for the practice of botanical medicine, a standard that cuts across professional categories and maintains the focus on identifying the quality of knowledge that practitioners offer the public.

Health care under our legal system is primarily the concern of the individual 50 states. However, this model presents unusual problems in CAM because so many different types of professionals use herbs. How can we accomplish reliability if standards differ, not only state to state, but from profession to profession? And how do we achieve a standard for Western herbal practice that also allows traditional healers to continue their practices? The BMA believes the public can achieve this reliable standard through a voluntary exam that measures only knowledge of the use of Western medicinal plants. After all, consumers should be able to assume that all practitioners prescribing herbs have the same degree of knowledge about the plants they use.

The BMA, working with the American Herbalist Guild, will this fall offer the first exam that measures that knowledge. The first exam will be directed to advanced clinical practitioners, but we will soon be offering a basic exam to practitioners entering the field. These exams will cover usage, dosage, side effects, interactions with other medications, quality of products and other such topics. The resulting certification will empower consumers to access quality information about the herbs they want to use. And it will set a bench mark that schools can model their educational programs to and give the government a single standard to monitor.

A policy decision to support and fund a single voluntary standard for all professionals will help the public enjoy the benefits that alternative medicine has to offer. Thank you.

GORDON: Thank you very much. I think the way we'll do questions is we'll start from one end and move on up. It's easier and then each in turn, if you'd like to ask questions please feel free.

Questions from Commissioners

MAN: I have a question for Dr. Lyons. Dr. Kelley spoke about health disparities and it has been a theme that has come up and Ms. Wong has some data here on utilization of services. Has your region access to any systematic look at utilization with a specific focus on health disparities regarding CAM therapies in the region?

LYONS: Yes, we have access to a lot of information about that through our associations with the CAM schools. And actually my office has funded two special projects to look into the health disparity issue in underserved populations. So those activities are at Bastyr so we're very closely connected to it. And one thing that I probably didn't mention in my testimony is that I think the crucial thing that we have in this community in terms of an asset is a close working relationship. We've met with each other for a number of years. Some of that is going to be brought out in future testimony, and we're connected. We talk together, we have fun together and we're becoming close associates just in the last few years. I think in like about three or four years. And so we exchange information a lot and we collect sources of information relevant to extending the services into the underserved communities.

MAN: Regarding you mentioned that massage therapies, you have 1,200 in this state. How do you get registration? For instance, what is training program to be registered if it's not a license?

MAN: I'm sorry, Doctor, I'm not the expert on that. I think Lori Bielinski would be because she's a massage therapist and works in the insurance commissioner's office so I really can't answer that question.

WOMAN: This is actually to Dr. Ziegler. The data that you have been collecting on utilization and poverty in the underinsured or underserved, how long have you been looking at that in a collaborative way? One year? Two years? Three years? Is this a recent phenomenon.

ZIEGLER: We've actually just started the process. And what we're doing is an apprec(sp?) inquiry survey of Bastyr and Northwest Indian College. If you're familiar with apprec(sp?) inquiry you look at what's working, why it's working, and a vision of the future. And it's much more powerful than looking at the problems and trying to build from there. And so we're doing that in terms of the public health activities within Bastyr, within Northwest Indian College and then looking at how we can create through that combination a stronger career ladder for our Indian community, as well as stronger public health entities within both Bastyr and Northwest Indian College.

WOMAN: Thank you.

GUTIERREZ: After 37 years I didn't know there was a Northwest Indian College, so that's helpful information.

GORDON: Effie.

CHOW: I appreciate all the deliveries very much. Being in Washington the Northwest is in a leading field of the development that we are looking for models in which we could perhaps look at and pattern and I would like to ask if it's possible for you, Dr. Lyons, and the others, to present a more detail of how to. How did you reach this progressive state and perhaps be helpful to us as Commissioners in a more detailed forum. I really appreciate the creativity that has happened here.

LYONS: I'm sure most of us would be very eager to do that. We enjoy having those kinds of discussions and sharing information and we would entertain that. I think that, I like the concept of assets which I mentioned, and I think there's probably a critical number and type of assets that need to be in a community to make a really good environment for the advancement of CAM issues. And I think we just happen to have a lot of them here. And we've enumerated some of those. And I think getting a good list and figuring out which ones are the most important assets is a real critical step. And we'd love to work with someone about that.

CHOW: Perhaps we share some of those secrets.

WOMAN: I appreciated all the comments as well. I have a question for Dr. Lyons and Dr. Ziegler. Coming from New Mexico, I'm also from a very large underserved state and as a physician have worked in those areas. I am curious that naturopathic physicians and licensed midwives are being considered now, or are going into underserved areas and are being able to extend loan repayment or having loan repayment done, which I think is fantastic and a real step forward. But those are models that actually work within more of a Western paradigm, so they're easier to adopt. But I didn't hear anything about chiropractors or acupuncturists which also could benefit from that. I just wondered where that was at or if that's something that is being considered for underserved areas as well?

MAN: I'm sure that it is, and there are experts here that are going to give testimony on that loan repayment program that can answer the question much better. So I think we have probably refer to that. But I think they stick the first categories of naturopathy and licensed midwifery just because those were easier for them to deal with at the time and to get malpractice coverage and things like that. I'm sure their intention is to expand that. And I think it would be a good model to use in other parts of the country.

MAN: I concur, that's what my understanding is as well. This is the beginning of the wave, not the whole thing.

MAN: On botanical medicines, may I ask, is the process of establishing authority within the academy of what dosages, what clinicals, all of that research? Is it possible for you to establish an authority of where that standard should be? And secondly, do you envision that we would be able to project that same model into a regulatory world?

ABASCAL: In the exam context it's a bit easier because where there are disputes sometimes it's enough for the practitioners to know the different points of view and to explain them to their clients. And it's easier to test within a more open ended context of what might be appropriate, what the risks are, the benefits are. So we can test a knowledge base I think much more easily than we can actually create a hard standard that comes about when you try and legislate. And I think that is part of the reason a voluntary peer created and peer maintained system certainly initially provides such great benefit. Because we have all of the various professionals coming together, the experts in the field, finally articulating very specifically what we know, what we need to know, how we should test it and how we should educate it. And we're finding that just creating the exam has provided us with substantial knowledge that we were lacking previously as we tried to design educational programs. So it's a very interesting process.

GORDON: I have a question for Dr. Ziegler. I'm wondering if the guidelines for training CAM practitioners in public health, if you have those guidelines now and if we could have a copy of them?

ZIEGLER: I don't with me, but I'm sure we can get you the guidelines. And they vary again, the comment earlier about variety of CAM professions, you have a variety of CAM professions and so you're going to have different guidelines and certainly.

GORDON: I think this would be very helpful. What you're raising is a whole issue that would be very helpful for us to learn more about and the wonderful thing, as we listen to you is that so many of you and so many, I'm sure, of the people who will be speaking to us today have already taken the kinds of steps locally, and we really need your experience to help us shape national recommendations. So I hope that we'll also have that detailed information about the loan repayment forgiveness plan as well. That will be very helpful to us. Thank you all very much.

Speakers

GORDON: Next panel is Lori Bielinski, Kent Pullen, Alonzo Plough, and I'm still going to say, is it Maggi or Maggi? Maggi. I have a friend named Maggo, so, is your last name Italian?

FIMIA: Right.

GORDON: Right. Okay. That's my confusion. I'll surrender. First will be Lori Bielinski please.

BIELINSKI: Good morning. My name is Lori Bielinski and I'm a licensed massage therapist and a senior health care policy analyst at the Office of the Insurance Commissioner. In 1993 health care reform legislation was enacted in Washington that assured consumers could buy health insurance even if they were sick or changed jobs. Simultaneously, provider groups pursued inclusion of all licensed health care providers for insurance reimbursement within their respective practice scopes. To preserve the insurer's ability to select competent providers, the final legislation settled on the term every category without mandating inclusion of every individual practitioner. Subsequent revisions preserved these reforms and the Office of the Insurance Commissioner promulgated rules to implement that intent. An unusual footnote is that of the many sections of these reforms, this is one of the few portions of the law that remains. It has stood challenges in both the democratic and republican legislative majority, it has generated the most controversy, and is the most popular, as well as having been upheld by the U.S. Supreme Court.

There are specific criteria that must be met. The CAM professions must be regulated by the Department of Health with licensure or certification. The scope of practice must allow the provider to treat the condition that the patient presents. The provider must be contracted to be eligible for reimbursement. And finally, the patient must have benefits covering a condition that is within the scope of practice of the chosen practitioner. This is not an any willing provider law, nor is it a mandated benefit law. It allows consumers access to a choice of the provider who will treat the condition in which they are seeking care. Carriers have the right to credential providers as long as the standards are consistent with those established by the Department of Health. Carriers must not set network adequacy requirements, excuse me, they must set network adequacy requirements based on the number of covered lives in a jurisdiction where they are responsible for providing coverage. Carriers have the right to set the coverage limits, including services of CAM providers. The OIC has established rules that state these limits may not be unreasonable and may not be set by provider type but can be set by covered services. And the carrier may not exclude a particular category of provider altogether, nor can it cover certain provider types only by a separately priced optional benefit.

Thus, it became very important to clarify to insurers, providers, and the public that the law relates to all regulated health professions and not just those considered those alternative. Additionally, the law does not mandate a benefit for anyone. It allows patients access to the provider of their choice for covered conditions.

The initial environment impacted by the threat of ongoing litigation. After many discussions, parties agreed how to establish a joint work group and hire outside facilitation. It was agreed that the OIC would convene clinicians from the carriers and the professional associations to focus on clinical issues. The full work group agreed that all decisions would be made by a planning committee made up of a smaller group of the whole to assure that all parties were represented in the decision making process. Participants included outside facilitation, CAM professional association representatives from acupuncture, chiropractic, dietician, massage therapy, licensed midwives, and naturopathic physicians, medical directors from carriers and CAM provider networks also.

In the second and third year we expanded the work group to include primary care physician organizations, educational institutions that train the CAM professions and the State Department of Labor and Industry's Our Workers' Compensation Program. The group's '97 work was spent developing trust, building working relationships and establishing agenda. The '98 agenda was very aggressive, including coverage decisions, technology assessment, medical necessity, and most significant was the training of CAM practice guidelines. The 1999 clinician work group activities were focused on the known integrated clinics and additional training on practice guideline development.

The most important deliverables were the final report which you've been handed out, and draft seed algorithms for at least one condition for each profession. They are in appendix I of the report with the stipulation that they are drafts and have not yet been tested, implemented, refined, or subjected to peer review. Each profession has been encouraged to continue develop algorithms using the peer review process.

In this process we learned that developing trust and understanding of each other's language was critical to a positive outcome. Continuous representation assured participants that everyone was invested in the process and could build on those relationships. We believe that the next step should include research, not just of clinical efficacy, but of true utilization of CAM services in conjunction with or in replacement of normally covered conventional care. Case management considerations should be addressed, and education of all entities is the most important byproduct of such an effort.

Finally, a national forum of this caliber or multiple forums in several locations can break down barriers to trust and understanding of CAM services and eliminate divisive action by people or groups that are operating in a noneducated environment. This is a consumer demand and we as policymakers have the responsibility to move the decision making into well rounded, deliberate discussions about cost, access, and outcomes.

GORDON: Thank you very much. The next speaker will be Kent Pullen.

PULLEN: Since I will be talking about the role of King County in promoting natural medicine, I should begin by defining natural medicine. Natural medicine refers to healing through a better lifestyle and with the help of natural substances. We seek to correct deficiencies by putting into the bodies substances that belong there, such as vitamins, minerals, amino acids, enzymes, hormones, and digestive aids. And we seek to take out of the body bad things that don't belong there, such as toxins and allergens. Natural healing begins with a good diet. It includes eating natural whole foods, not processed or refined. It includes avoiding chemically altered foods, such as trans fat and avoiding additives, such as food coloring and chemical preservatives. It includes the use of therapies like chiropractic, acupuncture, and homeopathy which help the body to heal itself.

In 1994 I was curious to see if the county could promote better health care. I began by getting advice from a number of local leaders, Merrily Manthey, Dr. Joe Pizzarno, Dr. Jeffrey Bland and Dr. Jonathan Wright. I think you'll be hearing from most of this talented group, although at the present Dr. Wright is in Asia. But he did leave a videotape for your viewing.

I then consulted with my fellow elected officials and found that 11 of the 13 members of the County Council were already using natural medicine and were quite happy with the results. Encouraged by this support, I introduced a motion calling for the creation of a natural medicine clinic. The motion was adopted unanimously and we began getting a lot of help from a variety of sources. We were able to secure funding to open the clinic. Tom Trompeter of the Community Health Centers of King County agreed to manage the clinic and did a superb job. Bastyr University provided support in many ways. The staff were wonderfully cooperative and proved that conventional and alternative practitioners could work side by side in harmony. But most important, the natural medicine clinic was a huge success and the patients loved it. We received testimonials from some patients who said they've been trying for 20 years to solve their medical problems without success, until they were made well at the natural medicine clinic.

I'll conclude by noting that we have since made additional progress by incorporating natural medicine into health benefits for employees and we've begun planning to integrate natural medicine with conventional medicine. Why have we been so successful? I think it's because the Seattle area is quite progressive and because we have so many outstanding leaders here, such as the people I previously mentioned. We look forward to further progress and greatly appreciate your interest. Thank you very much.

GORDON: Thank you. Alonzo Plough.

PLOUGH: Thank you. My name is Alonzo Plough. I am the director and health officer of the Seattle King County Department of Public Health, Associate Professor of Health Services in the School of Public Health University of Washington.

I am very very pleased here to talk about in general, but what have to be the local underpinnings of partnership in order to transform local health systems so that complementary medicine, public health, and primary care can develop integrated models. And I'll speak in particular about our role in the King County Natural Medicine Clinic that Mr. Pullen identified. But I want to particularly emphasize the importance of the integration of public health practice and complementary alternative medicine as a transformational principle for the U.S. health care system in general.

When I came to Seattle and King County from being Commissioner of Public Health in Boston and in my confirmation hearings with the King County Council, I was surprised by a persistent line of questioning from members who are sitting with me right now. And those questions were about my proclivities around complementary and alternative medicine, how did I see this fitting into the role of the health department I would be taking over. An unusual set of questions speaking to an unusual practice environment. I was very fortunate, I never knew how fortunate it was, that I had played a role in developing the first acupuncture clinic in a teaching hospital in Boston at Boston City Hospital and used that example at least to say that I've had some experience and wanted to get more in doing that. I hope that played an important role in my being confirmed. But I realized immediately that I was in a very different practice environment with lots of different possibilities for the promotion of health and well being in the region. And the kinds of leadership and local leadership that the King County Council demonstrated through their natural medicine motion which Mr. Pullen just described and I will not, has really set the tone for the work that my department has been able to do over the last six years. And allowed us to develop a practical and grounded approach to, again, recognizing the real importance of public health in complementary and alternative medicine as the main catalytic partners in increasing prevention and well being focus for the entire U.S. health care system.

So again, a guiding local vision by elected officials was certainly key to the changes we've seen in our region and it was very exciting to me today that four members of the King County Board of Health are with you today.

Our King County Natural Medicine Clinic, of which you'll hear more about from some of the folks who are working with that on the ground later, was a partnership. We called it a three legged stool, between public health, community based primary care, and CAM. And I think those three legs are really what made this very exciting. It was a partnership between the Public Health Department, Bastyr University, Community Health Centers of King County, with some evaluation and statistical work done from the University of Washington. I think that the ability of these institutions to collaborate around this activity was really important, and I think it took particular strength that we have in our region with Bastyr, Northwest School of Acupuncture and Oriental Medicine, the International Foundation of Homeopathy, many strong partners in doing this. What makes this partnership work I think was the respect of each of us of our different traditions. And I think that was a hallmark of the startup of the King County Natural Medicine Clinic. And I'll just note a few things that I think were particularly important.

This clinic was the first publicly funded integrative clinic that integrated alternative medicine, public health, and primary care. It was the first clinic to partner with a local public health department.

GORDON: We're on such a tight schedule. Could you submit those to us.

PLOUGH: I will.

GORDON: Okay. Thank you. I'm sorry to interrupt.

PLOUGH: Submit the?

GORDON: The characteristics to us.

PLOUGH: Fine. Should I just go on?

GORDON: No. If you could do it in 30 seconds, yes.

PLOUGH: Then I'll just conclude then. Again, I think that what we've seen in the clinic is a focus on prevention, a focus on the integration of the two traditions, and I think that's really key to transforming health systems.

GORDON: Thank you. I'm sorry we have to be tough with the time. We very much want to review the written material as well. So if you can't get it all into a speech, know that we're going to be taking a look at it. Maggi Fimia please.

FIMIA: Maggi Fimia, King County Council and I spoke before. I just wanted to touch on the potential role of government here, both federal, state, regional, and local government and what I see as our role. The public in this region, and I can't speak for the others, but my sense is probably other regions as well, are way ahead of their governments in the establishment, in recognizing that there is a continuum of health care, it's not an either or. They want access to all different forms of health care, but they want it to be health care that actually works and is effective. The need is tremendous for us to address this issue now. We are working on our King County budget, for instance, right now and have found out that in 1998 our per employee health care cost was $480 a month per employee. Two thousand and one, the budget that we're looking at now it's up to $654 per employee. That's a 36 percent increase over just those three years, and we have 13,000 employees. We're just one government. This is happening to businesses and all governments. Clearly we want to make sure that with these tremendous investments in health care we are getting an equivalent or greater benefit in seeing increased wellness, not just attacking illness, but increasing wellness.

So government's role I think is to provide the forum to allow the different modalities to come together with both providers and the consumers of health care to set the tone for those forums so that people are willing and able to listen to each other and we know personally that we don't listen very well or learn very well if somebody is yelling at us or telling us that we're wrong and that what we've been doing for the last 30 years is incorrect. It doesn't facilitate change and tolerance. So government's role, if we're going to take one, is to be the referees and to set the tone that this will be a forum for increasing tolerance and listening to each other and recognizing that there's great value to what everyone is bringing to the table.

And to that end, we have set out a process here in King County called King County 2010 Integrated Medicine. Our goal for that process is to create an actual strategic planning document at the end of the process which would do three things.

First, celebrate what we've all accomplished, all modalities and all disciplines, over the last 30 years in terms of integration and promotion of wellness. And then to map out where we are now. Take an inventory. The town hall meeting has sped that process up and we are just absolutely very amazed and proud of ourselves for the list of speakers that are coming today, which is basically the beginnings of that inventory of what's happening in the region. And third to collectively decide on five to six goals that we can accomplish much better if we pull together and put them in a strategic planning document, identify who should take the leads on those different goals so that by 2010 we can look back and say, look what we accomplished together so much better, so much more collaboratively and effectively than if we had tired to do these things by ourselves. And they would be in the areas of research, of teaching, of cross training, of actual delivery of health care, and in insurance. Those seem to be the broad areas where people seem to think we need to have the most work together. Thank you.

Questions from Commissioners

GORDON: Thank you all very much. We'll begin with questions from the other end, with Tom Chappell. Come closer to the mike. Speaking of the mike, can people in the back hear all right? Yes? Okay, great.

CHAPPELL: Maggi, I think I may have missed the nature of the collaboration you were speaking of when you talked about the five or six goals, things, you have something working now.

FIMIA: Yes.

CHAPPELL: I was just wondering, did you plan on extending that collaboration?

FIMIA: We have been working for two and a half years. We started with a small group of people that we knew on our radar screen, pulled them together from all the different practitioners and insurance commissioners, from the government research education and implementation and said, first, do you want to do this? Is this a good idea? The answer was yes. The County has taken the lead to do the staffing for this, along with Bastyr and some other institutions. It's been great. And then we said, okay, who is the next circle of folks who should come to the table? Who else do you know about that should come to the table, look at what we've produced so far as far as accomplishments and potential goals. We've done that and had 50 people instead of 20 people. We are working on the next round of making that a 200 person, so that there are actually more consumers of health care at that table, bringing them the draft information and documentation that we have already and saying, are we getting this right? What else should be included in on recognizing the accomplishments, mapping out where we are, and are these goals ones that you could concur with and should they be more refined as far as goals? How do we measure our success? So yes.

And then to actually go after funding collectively so that we're not at cross purposes and that we have money to actually implement this strategic plan. And set up some sort of institutionalized or recognized body where all these different groups can be coming together on a regular basis and have something formalized as far as structure so that we can update the plan as necessary.

GORDON: What we'll do is just move down the line. If you don't have a question, just pass and we'll go through.

WOMAN: Sure. Dr. Plough, something that we hear over and over again is about research based medicine. And this is in some parts of the country the excuse that's been used not to have integrative centers because some of the modalities lack research or evidence based medicine. It seems that your clinic is an ideal place to do outcome studies, clinical audits, case series. Is that being aggressively done at your clinic so that that research can become available so that we can actually look at therapies and if they save money, if they work for what, etc.?

PLOUGH: We've begun some of that in the initial evaluation of the clinic. But I think only just the tip of the iceberg of those kind of studies. I do agree that it is a site where, if those research funds could be acquired, those kinds of evidence based questions could be addressed.

WOMAN: Funding. Money.

PLOUGH: Funding. Exactly. Those are very expensive. To do the kind of evaluation we would have liked to have done, to look at those outcome measures would have been multiples of the money that we had invested from the County to start up the clinic. So we were very much in need of those research dollars.

WOMAN: Mine deals with money too. And regarding the insurance, we're always frustrated with treatments being paid and there is no effect. And then when there is treatment that is effective there is no payment and people have to pay out of their own pocket.

Is there any thought in the insurance field that you pay for what is effective and not for what is not effective? There is rumbles of choice, there's a freedom of choice.

WOMAN: Be careful what you wish for.

WOMAN: And how far out is that? Because funding CAM seems to be far out before, but any comment about that?

BIELINSKI: I think it would be remiss for me to answer on behalf of the insurers. And since we regulate them, but it is the ongoing question. There are several people here in the audience today from the insurance companies and will be available to answer that from their perspective. There is also a speaker that is going to address you today about a study that he is preparing to conduct on CAM research, add on versus replacement costs, with three of the insurers in the state. So I think it's just starting. And again, it's about funding and proprietary information.

WOMAN: I'd like to address my question to Councilman Pullen. As your natural health clinic expands, I'm wondering if there is what amounts to a consent for care for the patients so that they have an outcome expectation. And I would think that a document such as that might allow for more integration and public education both in the process.

PULLEN: Well, I agree. And I believe that some of that is now being done at the clinic. And you have representatives here today representing the community health centers of King County which has managed the Natural Medicine Clinic and is now integrating natural medicine into all their clinics. And I believe at the appropriate time they can expand on that. But I do believe they've done some of that already with patients.

MAN: My question is, you mentioned that so many programs, like CAM therapies can be reimbursed or can be covered and does the patient have choice, for instance, to try chiropractor massage, acupuncture and herbal medicine, everything at the same time? It will cost a lot. Is that necessary? And you have to have a guideline to let patients have some choice.

BIELINSKI: The law is based on already covered conditions, so the patient presents with a complaint and it has to be diagnosed. One of the models of coverage which is referenced in the report talks about the gatekeeper method where they would have to see a primary care provider. One of the insurers in our state does credential naturopathic physicians as primary care providers. So that's one level of entry. There are many levels of entry which require a referring doctor to diagnose. When they diagnose the condition then they work it out with the patient what their benefits cover and what kind of provider they want to treat that particular condition. The herbal therapies are not covered because there is no standard at all of what is actually in the herb. There was one insurer at one time that did cover up to $300 per year for some herbal medicines, but that's no longer available. So they still have to have benefits to cover the condition. It's a matter of choice of provider of who is going to treat an already covered condition.

MAN: It would cover massage therapist? He's licensed or registered?

BIELINSKI: It is licensed. We have a 500 hour education requirement. There are approximately thirty some schools in Washington. And yes there are . . . and again they must already have benefits for the condition they are diagnosed with.

MAN: Impressive, thank you.

MAN: A question for Dr. Plough. Just looking at the report from the State Insurance Commissioner there are a lot of feedback loops here. And it's very commendable how at sort of the policy level of the various CAMs that have come together to work collaboratively. But how do you operationalize this? Do you have any concrete recommendations to foster collegiality, communication, continuity versus discontinuity of care between the range of practitioners who are on paper working together here?

PLOUGH: You may hear more from this in the panel to follow, but we found in the startup of the clinic it was very important to spend time with the practitioners doing cross learning activities and fostering that and recognizing that that takes some time. In a system that separately trains practitioners it takes an investment to get that cross learning to happen. So I think that was very critical, that that time be given in an integration activity and that be reinforced and supported. I also think in the example that we had I think it's generalizable nationally, local public health departments and federally funded 330 primary health clinics are natural incubators for this kind of collaborative activity. And I think that the kinds of things that you see from our natural clinic model could be generalized as a kind of place to incubate these kind of integration practices.

MAN: If you could just make available to us any of the curricula that have been used for that cross learning it would be most helpful.

PLOUGH: And we have a large qualitative evaluation of just the cross learning phase of the intervention which we can also share with the . . .

MAN: That's what I was going to ask as well. Obviously I haven't had a chance to look through this. Do you have an assessment of how you're doing and how you're doing economically in terms of coverage issues? Maybe that's more addressed to you, Lori, than.

BIELINSKI: We don't have any of the studies done yet. As I mentioned, Dr. Bill Lafferty is in the audience and we'll talk about an NH grant that he has applied for to do some of that. We've been trying to get various projects to look at utilization costs. There are some cost benefit analysis done by . . . and Robertson for pricing various CAM services. But I haven't seen one that's unbiased yet. And I'm not an actuary.

GORDON: Let me just say that I think, I think I'm speaking for all the Commissioners, it what would be very useful is any data that you could give us about cost benefits of the new regulations. Or even a descriptive sense of what has happened with whatever approximate dollar amounts you can attach to it. That would be very very useful for us to consider.

BIELINSKI: That would be a very good collaborative project for me and the payers.

GORDON: Okay, sounds great. Thank you all very much.

WOMAN: Thank you. If the following speaker who I think missed her slot, Gail Zimmerman, if you want to come up now, and we'll also take the following eight people. Tom Trompeter, Judy Featherstone, Kathy Lynn Boulanger, Pam Snider, Leanna Standish, Jeffrey Bland, Richard Hammerschlag, and William Dallas.

Speakers

GORDON: While people are coming up, it's wonderful to see so many people who have been working in this area for so long and done such wonderful work all here together. That's great to be working with you. And I like the idea of those collaborative efforts. Let's begin with Gail Zimmerman then.

ZIMMERMAN: Good morning. My name is Gail Zimmerman. I am an Executive Director with the Washington State Department of Health Health Professions Quality Assurance. I have oversight and presently work with 16 health care professions. The Health Professions Quality Assurance Division in the Department of Health is responsible for promoting an effective partnership between the Department of Health, the professional licensing boards, commissions, committees and councils, the public and health care professions.

I have been asked to share with you the licensing, disciplinary, and regulatory activities relating to all health care providers in Washington state. The Department of Health is charged with protecting the public and safety by regulating the competency and quality of over 240,000 health care practitioners. We provide in Washington 52 different types of licenses, certificates or registrations, and we work with 26 boards, committees, councils, and commissions to regulate the health care professions and services in Washington.

In conjunction with the above groups, the Department sets standards for professional practice. We review applicant qualifications and backgrounds. We receive and process consumer complaints for all of the 52 different types of licensed health care professions. The number of active licensees in Washington has increased in 1991 from about 164,00 to 240,000 in 1999. That's about a 46 percent increase in the last ten years. We at the Department have several quality assurance mechanisms that we use to assist both the public and the health care practitioners to obtain the most up-to-date information and help available. Regulatory reform in Washington has provided an excellent opportunity for both public outreach and input into our regulatory framework. We have an automated verification service which allows hospitals, insurance providers, and managed health care organizations to obtain information on health care practitioners 24 hours a day. We have one standardized application and review process to credential all 52 of the health care professions. And all professions in Washington use regional or national exams except in those professions where they may not be available.

We in Washington also our public disclosure process allows the public access to information concerning health care practitioners. All credentialed health care providers in Washington fall under one disciplinary act with standardized procedures for the licensure of health care professions and the enforcement of the laws for the purpose of professional conduct. The Department has adopted procedural rules for the disciplinary and adjudicative processes. These rules include provisions for setting time periods and establishing specific time lines for each of the steps in our adjudicative process. We also have threshold criteria that have been established in policy for all cases to decide up front whether a case should be closed rather than to expend the resources. We have developed case disposition criteria to apply to all cases requiring investigation to help determine the appropriate action, including both informal and formal disposition.

We have been able to achieve these results through a collaborative effort on the part of our legislature, the public, health care providers, associations, government agencies, and other stakeholders.

I have provided staff with a report that outlines in more detail the work of the state and it also will provide you with a list of all the health care providers we credential in Washington. Thank you.

GORDON: Thank you very much. Tom Trompeter, nice to see you.

TROMPETER: Welcome back.

GORDON: Thank you.

TROMPETER: My name is Tom Trompeter. I am the Executive Director of Community Health Centers of King County. We are a private nonprofit community health center which receives a variety of grants sources of support from the federal government to our local King County Council and the local health department. We have six medical and four dental clinics spread throughout suburban King County and we are providing integrative medicine actually in two of those medical clinics now. Our patients are diverse and economically disadvantages. Ninety-seven percent of our patients have family income under 200 percent of poverty. Forty percent plus now are uninsured.

Since 1996 we have been involved in establishment of an integrative medicine clinic known as the King County Natural Medicine Clinic which is housed at our Kent Community Health Center. And I would like to express my appreciation for Mr. Pullen's kind words, but there are many others who have been involved in bringing this to fruition, including my former boss at the Health Center, Jane Lee and Marty Ross, our former medical director. You'll be hearing later from our current medical director. All of the providers, all of our staff, and I think most importantly our patients. One of the primary impetuses for us to even get involved in providing integrative medicine was we surveyed our patients and sixty percent of them said that if these kinds of services were offered that they would take advantage of it. We are a community based organization. We try to meet the needs of our community. So we are fortunate enough to be able to take advantage of funding opportunities to be able to bring this to fruition.

Currently we have on staff naturopathic physicians, acupuncturist, we have one acupuncturist employed and we are also engaged in a teaching collaboration with Bastyr University to provide acupuncture services as well, as well as a licensed massage therapist. Massage and chiropractic are also available services via referral from the practitioners in our clinics.

I think it's fair to say that at this point in time we have a rather well-functioning integrated clinic, but there's always more work to do. But one of the things that really, or a couple of the things that really support this is constant peer cross training and cross referral. Another thing that I would like to mention in terms of the operations of our clinic is despite the bashing that managed care takes in many circles, we provide care to Medicaid managed care patients and to another program that Washington state has called the Washington Basic Health Plan. And the services of our naturopathic physicians and acupuncturists are we consider them to be covered primary care services within our own corporation. We get our own capitation dollars to provide those services and it is up to us to decide how to use them. And this is a decision that we have made.

There are a couple of things that I would like to say. About the systems mechanisms that have been in place, without which I think it would have been much more difficult, if not impossible for us to do what we've been able to do. One I think is consonants between the principles of community oriented primary care and complementary and alternative medicine. I think this is not to be understated. Community oriented primary care is the principle by which most community health centers, if not all community health centers, operate, in terms of looking at the needs of their patients, looking at the needs of their communities, emphasizing prevention and wellness. I think that this helped create a foundation that allowed us to move in the direction that we've moved with less trouble than might have happened in other environments.

Another thing that is really really not to be underestimated is that we have state licensing for CAM professionals. We have any category of provider law. We have supportive educational institutions such as Bastyr University and, as you've heard, we have local political and financial support, especially through the King County Council and the local Health Department. If there are some things that I would like you to walk away with in your minds as things to be done, better reimbursement under Medicare and Medicaid, clinical training for CAM students in community- based settings. This has been spoken to before, we need to have practice incentives for people who are graduating from CAM schools to work in underserved communities. This is talking about scholarships and loan repayment, whether that's at the federal level or the state level. And finally, from the folks who work in my part of the world, we need funding. It is not enough to simply do the other things. We need funding to help finance the services for people who can't afford to pay. Thank you very much.

GORDON: Thank you, Tom. In the interest of full disclosure, I worked with Tom in the clinic just as it was beginning to open and it's incredibly exciting to be there and to work with you all and I'm looking forward to coming over tomorrow.

TROMPETER: We have a fabulous new home.

GORDON: All right.

The other thing I want to say that I want to thank you particularly for, and say to all the speakers, is that we want exactly these kinds of recommends. Tell us what you want us to do, please. That's the most important thing for everybody. Thank you.

Next is Judy Featherstone.

FEATHERSTONE: I'm Judy Featherstone. I'm now the Medical Director of the Community Health Centers of King County. At the time of the establishment of our Kent Natural Medicine Clinic I was a family practice physician, and still am, in our Auburn clinic.

The concept of integrating the conventional medicine and natural medicine was rather uncomfortable for many of us when it was first suggested. Most of our conventional medicine providers had a lot of concerns, and those were particularly around our liability risks and adverse patient outcomes. Several steps were taken to allow this integration to proceed as well as it did and to allow us to have the program we have now that benefits so many patients. First was education of our conventional medicine providers about these alternative medicine practices. Most of us had little understanding and these providers were able to explain to us their training, their interventions and improved our common knowledge.

Next, to address the concerns about liability, a decision was made to hire only licensed practitioners. And this was reassurance to many of us. Addressing the conventional providers' concerns about the patient care was a bigger job. Shortly before the clinic opened a group convened that was made up of providers from Bastyr University and the community health centers to develop protocols for management of patients with specific diseases. This group created a list of diseases or problems that should be first seen by our conventional medicine providers. And those were many of the things we consider as emergency things: heart attacks, strokes, fractures. Most of the other problems, the patients were given a choice when they came in of whether they would see the naturopaths or the conventional medicine providers. This gave a lot of reassurance to the conventional providers and gave the naturopaths freedom to practice.

Since the integration clinic has been open we've used various tools to continue to promote the common understanding. There is an integrated medical record, there are meetings of all the Kent providers to discuss the integration, and there are monthly didactics for providers from all of our sites. And several of the alternative medicine providers have gone to our different sites to see patients with our conventional providers and give them input on patient care. Some of these teachings we could include in our practices, and we certainly developed a better understanding of what was appropriate to refer to our naturopaths and other alternative providers. Conventional medicine clearly doesn't treat all illnesses optimally, and our patients have benefitted by having a broader range of options. I'd encourage the expansion of this model throughout the country.

GORDON: Thank you very much. Kathy Lynn Boulanger.

BOULANGER: Actually my name is Candy Burke. Kathy is the President of the Washington Reflexology Association, but was unable to be here today. I am a co-founder of the Washington Reflexology Association and I guess what I'd like to say to you is that reflexology, if it's unknown to you, is an ancient healing science. It's consecutively been a body of work known all around the planet, used and relied on in every culture that, number one, does not access to medical care for its work in how it helps the body move into its own ability to heal itself. Science, by the way, has proven through time that it also can be a little flawed after statistics appear 30, 50 years later as new things evolve in the world and our understandings, we find that we have to kind of move the lines a little bit anyway. Reflexology is something that relies on very specific hand and finger techniques, working over hands, feet, and ears. It's a body of work that bridges all of medicine. It bridges all of CAM providers. It's a body of work that literally, because it's primarily done on the feet, supports, and that word is used very purposefully. It supports all the work that everybody else wants to do in the realm of care for the body.

In the state of Washington the work of reflexology has been governed by the law of massage therapy, and Lori mentioned that Washington state has 12,000 practitioners that are massage therapists. However, within that number, because that's been the guide for a lot of body attendance to work from, what's happened recently, just for your edification, is that people that do Shiatsu, people that do Aston Patterning(sp?), Feldoncrist(sp?), Reike(sp?), things like that, have been set aside as an exception to that law so they could do their work. Reflexologists now are engaged in conversation with massage therapists to become a certified program. And that then makes availability to the public that much greater currently in the city of Seattle. If you look in the phone book reflexology lists two people. Because my name is one of them, I am the recipient of a lot of calls that say, it sure is hard to find a reflexologist in this town.

In regards to insurance reimbursement to my clients, I only deal with reflexology now in my practice. I've been licensed for over 13 years as a massage therapist. My clients cannot go to their insurance companies who do provide for insurance coverage and be covered for reflexology, simply because it's just not known. Thank you.

GORDON: Thank you very much. Pamela Snider.

SNIDER: Good morning. I am Associate Dean for Naturopathic Medicine at Bastyr University, a naturopathic physician and co-chair of the Building Bridges Group with Dr. Lyons who you heard from earlier. I will address a key element helping to produce such effective collaboration in our region, collaborative working groups and specifically the Building Bridges Between Provider Communities Group.

The group is a coalition of agencies and organizations in the region with a mutual interest in the integration of alternative care. The group is one of the three core CAM integration work groups in this area. Members have worked well together based on a genuine desire to improve community health. The group's name became its mission. And its main activities were information sharing, immunization discussions (very interesting to note), and bridge building. As the membership developed, joint conference on diabetes and best integrated practices was held with the American Association of Naturopathic Physicians. Our follow-up activities were collecting data on the conference, issuing a report, and working to develop the Northwest Center and King County 2010 initiatives. The group has completed its work and is preparing a final report. Its members are active in the Northwest Center and King County Integrated Health Care 2010 initiatives. These initiatives are venues for local integrated health planning and institutional and regional public health partnerships focused on serving the underserved.

We feel we accomplished our goal, establishing strong working relationships, and we've become a stepping stone for collaborative efforts in public health. Licensed CAM providers established a sense of credibility about competence and our proximity to one another and a sense of shared mission have developed strong communities of action.

The joint conference on diabetes brought together a wide range of stakeholders. Seven hundred participants attended. Seventy-three percent said that their diabetes care would improve if they had better working relationships with other providers, especially CAM providers. We found that type II diabetes is an urgent problem in the country and must be addressed by CAM and conventional medicine.

We have six recommendations.

1. To fund and initiate bridges type groups in other DHSS regions.

2. Establish an immunization CAM task force in Region X.

3. Support regional and public health partnerships with CAM and conventional medicine with an

emphasis on serving the underserved.

4. Conduct regional conferences on integrated CAM and conventional practices to reduce preventable diseases.

5. Reimburse for behavioral change for CAM and conventional medicine providers. 6. Support local community demonstration projects and strategic planning to integrate CAM and conventional health services.

Thank you very much.

GORDON: Thank you very much. We're going to have a chance now to speak with, this is the first panel of five, so we'll start from this end this time. Joe.

Questions form Commissioners

MAN: We had a meeting in Washington a few weeks ago and we were talking about some of the research infrastructure, and this is for Dr. Snider. You were talking about demonstration projects. What kind of resources would you need locally to do the evaluation side of outcomes research?

SNIDER: I think you might want to ask the insurance commissioner's representative about outcomes research. But as far as community planning, we are very interested in applying for grants to further the kind of community planning and outcomes assessment of implementing those community goals. We haven't developed a figure. But I'm sure we could get back to you on that.

WOMAN: This is for Dr. Featherstone. I'm very curious about who set out the guidelines and what would be taught to the providers in your new clinic. You said you had educational providers, only licensed practitioners, and you develop protocols.

FEATHERSTONE: Right. The protocols were developed by a group of naturopaths and conventional medicine providers.

GORDON: One thing I'll say at this point, I think it would be really useful, having worked with other nascent clinics like yours, for you to make your experiences widely available as possible. Not just, we'll be able to do a little bit of that down the road, but I think in terms of spreading the information through national meetings of all different groups of providers will be extremely helpful. Go ahead, Tom.

TROMPETER: We have done that both through the National Association of Community Health Centers, as well as through our regional associations. And we've been visited by health centers from New York to California. And I will tell you one of the things that really gets to be a puzzlement for a lot of folks is when they lack state licensing.

GORDON: When they what?

TROMPETER: When they lack state licensing. When naturopathic physicians or acupuncturists are not licensed, it makes it very difficult for people to generalize the model.

GORDON: Could you provide us with the kind of information or the kind of packets that you're giving to people when they come to visit or that you present?

TROMPETER: Sure.

GORDON: Thank you. Veronica.

GUTIERREZ: My question is for Tom Trompeter, but first I'd like to say that I've worked with Gail Zimmerman and the health of Washington is in very good hands in the Department of Health. Mr. Trompeter, I was interested in your presentation. I'm wondering who, and even more importantly, what is the criteria for determining a referral to a chiropractor?

TROMPETER: Actually, that's a medical question and I'm just an administrator. But it's basically provider judgment. When benefit is to be gained in that provider's judgment to a referral. We don't try to hamstring people too much in this. But we do, particularly for us, because this is a cash out of our pocket expense. We have a referral relationship with providers in the community and we pay them to provide these services. And so it becomes a resource that needs to be managed somewhat carefully. Therefore, we give our providers the discretion to decide when they really need to send someone. And that's when it's out of house. When it's in house, it's a little easier for us to take care of. Does that answer your question?

GUTIERREZ: Yes.

GORDON: There will be someone, there will be a physician from the clinic, will be here later.

TROMPETER: Yes. Dr. Cindy Breed will be here later and Dr. Featherstone can also help answer some of those questions.

GORDON: Effie.

CHOW: I just have a simple question. Is Chi go(sp?) included in any of your practices or programs. Chi go(sp?), a Chinese energy exercise, self-help.

MAN: Not at this time. Again, it is a resource question, what we can afford to have on staff and what we can afford to pay for out of pocket which also goes to my last recommendation to you folks.

GORDON: Charlie. WOMAN: I guess I have a hypothetical question that we've encountered at similar practices in New Mexico. If you, as a physician, you have a patient you diagnosed with breast cancer, and she chooses that just really for her at this time, based on probably many beliefs, she just wants to do acupuncture and herbs. That's going to be her treatment for breast cancer. How is that addressed and handled within your clinic?

MAN: . . .

WOMAN: I thought you'd like that one.

WOMAN: I think because our providers work so closely together it allows much better melding and it's an area that many of the conventional providers aren't going to know a whole lot about, and so they can sit down with our naturopaths and the acupuncturist and learn more about it because they're right there in the same space. Then we always support the patients with their choices. And if they make a choice, no matter what it is, it's our job to support them and to allow them to have the life that they choose.

MAN: Tom Trompeter, the economic model I'm interested in, if there is one yet. And the practitioners are on staff. Is that correct?

TROMPETER: Correct.

MAN: Then could you give me some estimate of by percentage the various sources of funds that are sustaining the clinics.

TROMPETER: Sure. About 30 percent of our funds are grant funds, which is a combination of public health service grants and local grants. Some small amount of state grant money, the state of Washington actually is quite progressive in how it approaches health care, and there is a small state funded grant program for health centers, not unlike what is in California and a few other states. About 30 percent of our revenues come from patient fees, which is cash that our patients pay us on a sliding scale. And the remainder is a mix of fee for service as well as Medicaid managed care, as well as revenues from the other program that I spoke about, which is the Washington Basic Health Plan.

In terms of setting context, the community health centers in Washington state a number of years ago formed their own managed care contracting entity for purposes of being able to preserve our ability to provide services for Medicaid patients that had been coming to us before the advent of Medicaid managed care. And it is the vehicle which allows us to at least provide the professional services component of the naturopathic physicians and our acupuncturists on staff as part of covered primary care services within our own corporate walls.

WOMAN: Are they paid employees then, the naturopaths?

TROMPETER: Yes.

WOMAN: And are your Western trained physicians and naturopaths paid the same salary?

TROMPETER: No.

GORDON: Could you give us as much as possible an economic breakdown. I think we're all really interested, and as one of the longest running, and certainly the longest running public model.

TROMPETER: Sure.

GORDON: It would be very helpful. On paper.

TROMPETER: Yeah. I had intended to provide you all with some written testimony, but I wanted to wait to see what kind of questions came up as well. And certainly if after I provide you with information if you feel you need more we'd be happy to provide whatever you need.

GORDON: Terrific. Thank you. Thank you all very much. We'll go to the next panel now. We have a substitution. Leanna Standish is first. Please, go ahead, Leanna.

Speakers

STANDISH: Dr. Gordon, do I have five minutes or three minutes? It makes, wow. Oh, well, hello, and welcome to Seattle. It's nice to see your faces again and new commissioners. My name is Leanna Standish and I'm the Director of Research at Bastyr University.

I believe that the major obstacle to CAM research right now is lack of research infrastructure and training at CAM institutions that have true CAM expertise. Between 1992 and 1999 only seven CAM institutions received funding from either the OAM (Office of Alternative Medicine), or NCAM (the National Center for Complementary and Alternative Medicine), compared to 76 conventional universities. This means that only nine percent of CAM research grants have gone to CAM researchers who teach and do research at clinics and colleges that specialize in CAM and have for decades, not just this last year, because there is now research dollars available at the NIH. The reasons for this discrepancy include the fact that many CAM academic and clinical centers do not have research expertise or the infrastructure to produce high quality NIH grants. There is very little time for research. As you probably know, most CAM academic centers are tuition funded, and therefore, teaching loads are very heavy. There is a potential, and I think very serious risk of CAM experts not being actively involved in researching their own field. The risk is the potential and likely loss of the best ideas, the most significant concepts, and the most important CAM therapies.

If we are not careful as we move towards mainstreaming and integration we may lose the very best of the fringe ideas. The price of mainstreaming may be high indeed, camodification(sp?) and dilution of whole systems CAM practice. And a new green pharmacy that does little to improve either health or change the basic assumptions of medicine or science. And CAM's current, exciting; you know what I want to do? I want to go right to my eight recommendations, okay. And I will submit to you my testimony so you can see why I'm making these recommendations.

1. My first one is I recommend that NCAM fund planning grants to CAM academic centers in order to develop research agendas, clinical trials consortiums, and strategic plans. CAM research should be designed and executed by CAM experts with the help of experts from conventional medicine. Thus far, the emphasis has been placed in the other direction, that is research designed and executed by conventional universities with grafted CAM expertise. And because of this bias we risk losing the best science. 2. I think we should request NCAM that an RFA be developed specifically for CAM institutions to help them develop research infrastructure and a cadre of CAM experts who are also trained in research methods. 3. We should request the FDA to establish a CAM task force to develop policies and procedures for investigational use of CAM therapies.

4. In order to increase sample size and power of exploratory CAM clinical studies, NCAM exploratory research grants that now fund most of the research in this area should not have a cap of $125,000 a year. Rather, I would suggest we remove that cap and ask principal investigators to develop budgets based on the scientific needs of the research question. We have actually a system now that is biased towards the risk of type 2 errors at the NIH.

5. Allocate funds and authority to NCAM and other appropriate federal regulatory agencies to provide education to IRBs so that they can provide more informed ethical oversight of CAM clinical research.

6. Request a federally funded RFP process to fund research on insurance company CAM databases. We have a rich supply in the state of Washington. We must have an answer to the question of whether CAM use has additive or substitutive cost to the U.S. health care system.

7. Request the NCI (National Cancer Institute) to provide funding to CAM cancer clinicians to do the difficult administrative and clinical work of producing a best case series, and finally,

8. Fund programs to support prospective practice based outcomes research using a case series and weight list control method.

Thank.

GORDON: Thank you, Leanna. I see that Bob Learman is here in Jeff Bland's place. Bob.

LEARMAN: Thank you, Jim. I'm going to give you a summary of what we've submitted. In the past it was assumed that proof of safety and effectiveness of any therapy was secure only when there were well controlled clinical, randomized trials performed by well-respected investigators and published in peer review journals. Because many CAM therapies were developed outside of the pharmacologically-based medicine, they have not been subjected to randomized clinical trials and therefore considered by many to be of unproven value. An example is the work of Killmer McCully that worked on homocystine(sp?) and associated that with cardiac disease. And it's estimated that over the past 30 years that nearly a million Americans might have been saved heart attacks had full AB12 and B6 been given in their homocystine looked into.

So what can we do? We can try to find other approaches for evaluating the CAM therapies. CAM therapies are often complex in nature, involve more than one parapeutic(sp?) component tailored to meet the need of the unique patient and their effect may come across more than one patient outcome variable.

Clinical trials based on other methodology, such as cohort analysis, pattern recognition, statistical evaluation and multi-varied analysis or cluster analysis would be ways of getting about this. We at the Functional Medicine Research Center have been studying the influence of nutritional and botanical medicine approaches to chronic conditions over the past ten years and successfully applied multi-varied approaches to studying complex health issues such as chronic fatigue syndrome, fibromyalgia, veritable bowel, insulin resistance in hormone imbalances in women at our center.

I'll move directly to the recommendations that Jeff put together.

The first recommendation is to support studies that are designed with methodologies other than the placebo controlled trial to test CAM outcome safety and effectiveness. Second is to foster integrated conclaves of basic scientists, clinical scientists, and clinicians with varied backgrounds. Focus research on the core processes that are related to age-related diseases, and it's the end of the health span that we're most interested in, to foster a life without illness. Support research that moves from CAM versus drug approach to studies that evaluate health outcomes from broad based clinical perspective. Sponsor research that requires collaboration among medical school researchers, CAM providers, HMO providers, and CAM educational institutions. Support research that looks at the interrelationship among the biomedical, medical, economic, sociological, psychological, and spiritual components in the determining outcome. Provide educational grants to scientists who want to learn more about CAM therapies who are willing to add arms to their existing studies to evaluate the impact of CAM interventions in their work. And last, to fund basic science studies that evaluate the influence of CAM therapies on gene expression and functional genomics. Thank you.

GORDON: Richard Hammerschlag.

HAMMERSCHLAG: Members of the Commission, good morning. I am Richard Hammerschlag, Research Director at the Argon College of Oriental Medicine in Portland. I also serve as President of the National Society for Acupuncture Research and for 25 years, up to 1995, I was engaged in biomedical research in neurobiology. Research is my profession and my passion, and it's a challenge to apply my training in biomedical research in neurobiology to CAM research in general and acupuncture research in particular. It is especially exciting to be part of the unique CAM research community in Portland, which is home to two of the 15 currently funded NIH and CAM centers. And for Tom Chappell I'll just reinforce that this is Portland, Oregon.

I will focus my remarks on three questions essential to research. First, what kinds of CAM research are needed? Second, how can CAM research findings be better disseminated to health care providers, policymakers and insurers? And three, what strategies can be developed to facilitate the incorporation of research supported CAM therapies into conventional health care settings?

In talking about research, we should acknowledge that evidence-based medicine, the current watchword at NIH, means research-based medicine. It follows that CAM research, similar to conventional biomedical research, must be held to rigorous standards. But what kinds of CAM research should be encouraged? I suggest that greater consideration and funding be given to research that compares real world treatment options. Just as models of integrative medicine are being created, we also need integrative research.

When CAM therapies are tested side by side with conventional therapies, a richness of questions arise with major implications for clinical practice. These questions address how CAM and conventional treatments compare in terms of therapeutic effectiveness, long-term effectiveness, side effects and cost effectiveness. The Portland-based NCAM center at Kaiser Center for Health Research is initiating such comparative research in partnership with Portland area CAM colleges of Oriental medicine, naturopathy, chiropractic and massage.

The CAM community also needs to be more proactive in ensuring that its research findings reach the wider health care community. One approach is to prepare informational packets that summarize research findings, as well as educate health care administrators, providers, and policymakers in how to assess the quality of research articles. This would help to correct the major inconsistency in contemporary health care. We hear strong calls for evidence-based medicine, yet we have a health care community that is poorly trained to seek out and assess the quality of CAM research.

Lastly, we need to identify the obstacles that are slowing the incorporation of evidence-based CAM practices into mainstream medicine. Three approaches are surveys to document attitudes to CAM, discussions on CAM at national meetings of possible administrators, and demonstration hospitals where the integration of CAM practices can be evaluated.

In summary, I urge the Commission to first to call for research that compares real world CAM and conventional treatments. Second, to explore means of more widely disseminating CAM research findings, and third, to develop strategies to better ensure that CAM research benefits health care consumers. Thank you.

GORDON: Thank you very much. William Dallas.

DALLAS: Thank you very much Dr. Gordon. And thank you for allowing me to testify. May I complement all of you for the public service that you're rendering to the humanity at large and all the work that you're putting in, not only here, but behind the scenes. I hope I'll stay within three minutes, and I think that won't be a problem. My name is William Dallas and I'm President of Western States Chiropractic College in Portland, Oregon. Before that I practiced as a chiropractor in Lakewood, just south of Tacoma, for 27 years, and before that I graduated from the Palmer School of Chiropractic in Davenport, Iowa, in 1958.

I have three main points that I would like to share with you.

1. The chiropractic profession is in critical need of research to provide valid clinical outcomes data.

2. The chiropractic colleges need adequate funding to hire researchers and to provide adequate infrastructure for chiropractic research.

3. Chiropractic education and research need to interact and integrate their programs with other higher education environments that include all relevant disciplines in science and medicine. Chiropractic is at the point where priorities for survival are changing from political action to pressing needs for data defining a clear clinical role based on demonstrated outcomes. The profession has a strong patient advocate population, and consequently, strong support from state and political leadership. Even so, those in decision making positions regarding reimbursement and patient access are responding enough to answer constituent pressure, but in most cases with obvious reluctance. This scenario will prevail until enough supporting data is provided to allow objectivity in the process.

Another facet of the same problem is the difficulty in establishing standards of practice and care for the profession. All state and provincial boards of examiners who are charged with protecting the public face a daunting challenge of identifying and codifying an almost chaotic array of opinions, all having limited supporting data. Currently, we have over 60,000 practicing chiropractors with about the same number of interpretations as to what constitutes the best clinical answer for their patients. It's exciting but it's very very difficult to get much done. Until objective assessments under scientific conditions have been conducted, this frustration will persist and optimum patient health care compromised.

I'd like to digress just for a moment and talk about a project that we have worked at at our college for a number of years, and the difficulty that . . . we are under way with a program called Conservative Care Pathways, and all that is is a logical and seemingly simple process of bringing together chiropractic practitioners, along with medical practitioners, naturopathic physicians, and with osteopaths, to discuss what really is the best course of action for patients, out of time already. I took too long introducing. What I will do is submit the rest of the material in writing. I understand that has to be in by the end of the week, and I am perfectly willing to answer questions.

GORDON: Thank you all very much. This is a very rich panel. Joe, do you want to begin? Oh, Tom, go ahead.

Questions from Commissioners

MAN: Dr. Bland, at the present time, natural substances are not patentable. Do you think research would be improved if the laws were changed to allow for discoveries of natural substances.

LEARMAN: First of all, my name is Bob Learman and I'm the . . .

MAN: I beg your pardon. The picture was right in front.

LEARMAN: Right, I know, this says Jeff Bland. I'm standing in for Jeff. I'm the Medical Director of the Institute for Functional Medicine in Gig Harbor. I think that your point is well taken, that if there were ways of patenting some of these approaches that that might foster more rationale for companies to go out to try to find the research that, to do the research that could define other CAM treatments based on them. I think that it's probably also going to be necessary for the government to support research in this area because most companies cannot afford to put in the kind of research money the pharmaceutical companies can for the kind of botanical research I think you're referring to.

MAN: Thank you.

WOMAN: This is for Dr. Hammerschlag. The issues around real world CAM research is very similar actually for real world conventional medicine. Because primary care doctors are always confronted with, how much does this evidence base really affect me in clinical trials where you just narrow down to this really small group of people. So that's not usually what represents our patients in our practice. Much of the critique, what we keep hearing is that we need more research. And what we keep hearing from many of the researchers is that we've got to take out the confounders, which are the healers. We're the confounders basically. And when you've got diet and when you've got acupuncture and when you've got herbs and you've got this whole pathage(sp?), how do you figure out what's doing what for public dollars. If we're going to have reimbursement, who is going to pay for what and what actually is working. How would you begin to address somebody who said, we have limited dollars? What are we going to pay for? And what works? And how are you going to do this real world CAM research? Which I'm in support of, I just want to know how to do it.

HAMMERSCHLAG: This is a multi-level question. The ultimate goal, I think, in doing this kind of research is not to say the way conventional medicine, conventional research has the goal of saying, what treatment will work for all people with this condition. And what we want to get to is, what treatment will work for this person with this condition. And so the ultimate goal of comparative outcomes, and we do include an arm of conventional medicine in the comparative outcome studies, the ultimate goal is to determine what condition is best for which patient. And so we include a lot of quality of life issues, we include a lot of instruments that measure all kind of psychological profiles, belief systems. This is part of the research. We're not just looking at medical outcomes. And that, I think, needs to be the ultimate goal of this research, is to say when a person comes in to your clinic, how do we know which is the best approach for that person.

CHOW: My central . . . concern about the research methodology, etc., too, and most of you have mentioned something about that. Do you have other concrete recommendations that you can submit to us as guidelines of what this real world research is or other than clinical trials and so forth? I think we're really searching in that line.

MAN: I think between Dr. Standish and myself, we would be glad to develop a set of guidelines for you along these lines. I'm delighted that her recommendations overlap, but were really different from mine, and so I think the two of us together could do that for you.

WOMAN: Effie, thank you. You have been consistent in this concern of how to really do practice-based research. And I can only tell you this, that in my frustration, we are about to start a hepatitis C clinic. We've developed a science-based protocol. It's going to be a comprehensive protocol. We're going to enlist anybody who wishes to come and we're going to have very hard end point measurements every six weeks and we will see, from each case, whether there is a change in the kinds of measures that one expects to see, including quality of life measures. So what I would recommend is that in about a year we'll have some hard information about whether that approach really works or not.

GUTIERREZ: My question is for Dr. Dallas. Nice to see you again. I would like to know, in your role as an educator, how you see the role of chiropractic in the paradigm of wellness and quality of life versus treatment of disease or disorder.

DALLAS: Now I'll get my time. Basically we are, as you well know, Veronica, we are pretty much as a self-defined health care discipline that shows its interest or focuses on the biomechanical structure of the human body and its influence on various parts of the health system. Wellness is a part, and you might say that it's an adjunct, certainly an assist, to dealing with a patient. In other words, the patient isn't just treated from the standpoint of a biomechanical dysfunction or a subluxation, as we use the term, there are a lot of other considerations that should be made. Diet, general nutrition, lifestyle, ergonomics in the workplace, physical condition. All of those are a part of the overview of a chiropractic responsibility for the patient. As far as getting into any other areas, to date there hasn't been much movement in that direction.

GORDON: I'd like to, before I pass on to my colleagues, to ask all of you, and this is an expansion of Effie's request, to give us models of the kinds of research, the kinds of protocols you would like us to recommend, with whatever information you have at whatever stage about how well it's working. And, Bob, I would also like for you to give the wonderful example of homocystine, and whatever you can produce in terms of data, if we had but looked, at a sort of natural treatment for heart disease what could have happened and what happened when we didn't look at it. I think what we're doing is we're creating a narrative in a drama, as well as collecting data, and we need both. We need the data, but we also need the drama from the past that's shaping our recommendations, and we need the potential scenarios for what needs to happen. So we really would ask you to do that and make it as clear and concise as possible, so that when we make recommendations for legislation we can make recommendations about specific kinds of research programs.

Linnea.

LARSON: Dr. Dallas, you said that you had some impediments to osteopaths, naturopaths, M.D.s and chiropractors working together. What I would actually like it is you could do like bullet points on the impediments to their working together.

DALLAS: I would be very happy to. By the way it did work out well. When we finally got over the initial barriers in communication.

MAN: Could I just mention something in terms of the working together, that we now have a course called Applying Functional Medicine and Clinical Practice where we have physicians, M.D.s, D.O.s, chiropractors, M.D.s, R.D.s, and basically all the health care practitioners that learn an approach to care of the ill and through an approach that is science-based and patient centered.

GORDON: I think everybody knows that we will be working on, later on there'll be specific sessions on professional education. So we're, again, interested in your thoughts and suggestions about that as well.

MAN: Quick question for, what is the functional medicine, what is definition please?

MAN: Functional medicine is a patient-centered, science-based approach to medical care that looks for underlying causes of medical conditions and relying on those underlying conditions, treats them to improve function, physiologic function and improve health. I'm not sure whether that answers your question. That's kind of our basic definition. I could go into more detail if you like.

MAN: Dr. Standish, it's good to see you again. Let me ask you a question, sort of anticipating the homocystine story five years out. You mentioned you're doing some hepatitis C research, and I don't know what you're doing. But you're obviously going to assess quality of life, functional status. Do you feel that Bastyr and other settings like yours are hampered by a lack of a basic science infrastructure. In other words, can you do the viral load, can you do PCRs, can you look at pathology? In other words, are you only studying the things you can study? There are other things you'd like to study but you can't because you don't have the collaborations or you don't have the research infrastructure or you don't have the MRI machines to look at the impact of acupuncture. If you want to bring the research home, do you feel you have that basic science infrastructure to bring it home and do it in the places so that the ideas don't get lost in the way that you described earlier?

STANDISH: Happily my answer is no. I think that what we found at Bastyr is that collaboration with nearby University of Washington has been a beautiful relationship. Viral lodes, for example, are very high tech tests, and not even most hospitals don't do them. So we're relying on biopsies done at Harborview Hospital. We have a wonderful collaboration with Harborview and the University of Washington. So we're doing the standard kinds of tests, including the gold standard of liver biopsy, but also focusing on medical outcomes using, we're using the SF36 for functional status. So I guess my answer is, thank goodness we have the University of Washington. If that were not the case, then we would have to be shipping our blood by Fed X to another facility.

MAN: So the model that you think would be best to replicate would be, no pun intended . . . viral lode here, but the best case scenario would be collaborations of the sort that you described.

STANDISH: Yes, absolutely. But you know, Joe, just think about it. Any kind of research that requires laboratory testing requires a certified, valid, commercial lab, usually either in a hospital or associated with a hospital. And so this is not a constraint that's particular to CAM institutions.

GORDON: Thank you all very much. We're going to take a 15 minute break now. When the break ends, if the next panelists could come and sit, that would be wonderful. Thank you.

Speakers

WOMAN: Would the following speakers please come up to the table. Robert Mootz, Clyde Jensen, Jim Taylor, Karen Sherman, and also Suzzanne Myer, Jacqueline Obando, William Lafferty, and Charles Simpson, please.

GORDON: Thank you. We'll begin with Robert Mootz please.

MOOTZ: Hi. Ladies and gentlemen, thank you very much for allowing me the opportunity to address you today. I also must commend you on the hard work you're doing. The perspectives I'm going to offer come from three areas. Thirteen years in private chiropractic practice, eight years in academian research at a chiropractic college, and six years as the first doctor of chiropractic to hold a full-time health policy and health services research position within a state government agency. When it comes to the integration of CAM, Americans have already voted in terms of their preferences, utilizations, and expenditures. Nearly 15 percent of the U.S. population visits a chiropractor every year. Extraordinarily high levels of satisfaction have been documented with such CAM services. It's not a passing fad, as you know. Yet government and the greater health care system often proceed as though all CAM services are only a fringe movement.

From my perspective, the federal government has both an interest and obligation to constructively influence the future of CAM and health care in the following three areas. Provide meaningful federal support for CAM research and education. And I want to reemphasize what we've heard earlier today. Attain consistency in federal programs with national trends and priorities, something I haven't heard mentioned yet today. And I'll go into that in a little more detail. Promote collaboration and integration and expand the role of CAM within conventional delivery. We've heard about that already.

Regarding research and education, I'll speed through those comments and emphasize that in the written testimony I've provided you, I've outlined some of the things, and there's overlap with what other speakers have said. One thing I haven't heard relative to dissemination of information that's very tactical for the federal government to do would be to focus on getting National Library of Medicine indexing of CAM journals. The research dissemination and clinical information dissemination is much more readily achieved in that indexing database than the others where they are currently available, although there's a few. CAM disciplines must develop their own research expertise and infrastructure as we've heard that. I want to reiterate that, that is essential. Further, information necessary to the CAM professions to implement their own quality improvement efforts is absent, and that needs to be emphasized.

My second point regarding consistency in federal programs with trends, I want to emphasize that the federal government is behind the general public in terms of its coverage for many of its own health care programs. For example, chiropractic care is a core benefit in most personal injury protection workers' compensation programs and in health indemnity plans. Yet extremely restrictive and arbitrary limits exist in the very few federal programs that cover chiropractic at all. And chiropractic is in fairly good shape in the federal coverage compared to other CAM professions.

As an example of a meaningful effort at collaboration and integration, let me talk about my experience with the Department of Labor and Industries. In 1992 our department established a full-time chiropractic policy and research position. Many examples of benefits to both the state agency, the chiropractic profession, and more importantly, to the business and labor constituencies of the state workers' compensation have accrued as a result. One example is joint research between the Washington State Chiropractic Association, the Department of the University of Washington, which led to the adoption of an evidence-based fee schedule for chiropractic services. This has provided more robust coverage for chiropractic care, helped reduce administrative burden on doctors and department staff, and has made constructive progress in policy development without adversity, litigation, or excessive expenditure of resources by government or the community at the legislative level. Including a chiropractic policy maker has helped in this very important area. This is a template that could be templated around in other federal agencies and encouraged in other governmental agencies.

Another point that we need to make is that there is a distinction between incorporation of certain CAM procedures into conventional medical practice and the integration of CAM providers into patient care pathways. Overall management perspectives, lifestyle approaches, and doctor/patient relationships are pivotal in health care, and tossing a few CAM modalities into general family practice is not the same as integrating practitioners into constructive clinic environments, bringing extensive training skills and perspectives to the decision-making table. To illustrate this, consider reversing the scenario of chiropractor incorporating suturing and enseds(sp?) as a substitute for family medical practice. It doesn't work. I guess I'll stop there. Thank you.

GORDON: What do they say? Brevity is the soul of whit?

Clyde Jensen. You're not Clyde Jensen.

DOWNEY: I'm not Clyde Jensen. No. I'm speaking for Clyde Jensen. My name is Katherine Downey. I'm the Associate Dean of Clinical Education at the National College of Naturopathic Medicine in Portland, Oregon, where we offer advanced degrees in naturopathic and classical Chinese medicine. I'm here to present the testimony of our President, Dr. Clyde B. Jensen, who is the only person to have ever served as an executive in colleges of allopathic, osteopathic, naturopathic, and Oriental medicine. A death in his family has prevented Dr. Jensen from delivering his testimony in person. The following are his comments.

My experience in conventional and complementary medical education has convinced me that the best health care is integrated health care. Today I will make three observations with recommendations to facilitate the delivery of integrated health care.

First, doctors that train together treat together. In the rigid and often insular programs with which we educate physicians, there is little opportunity for medical students, interns, and residents to interact in any way but with their own kind. The products of these programs are distrustful of those who were trained in programs that differ from their own. I recommend federal support for integrated clinical training sites in which students, interns, and residents from conventional and complementary medical schools gain clinical experience in each other's presence.

Second, medical education trains doctors. Graduate medical education prepares physicians. Before conventional and complementary physicians can fully trust each other and confidently integrate their health care practices, their clinical training must be comparable in scope and in depth. The internships and residencies of graduate medical education programs provides the scope and depth necessary to confidently diagnose and treat. While graduate medical education opportunities are abundantly available for conventional medical school graduates, such opportunities for complementary medical school graduates are rare. I recommend federal support for the development of graduate medical education programs to prepare complementary medicine physicians.

Third, research is the common language of conventional and complementary medicine. The skepticism between conventional and complementary medicine providers can only be overcome by mutually acceptable research. To be mutually acceptable, research must be a collaborative process among conventional and complementary investigators. The research machine of the NIH and the academic medical centers can accommodate this research need if it is enriched with complementary medical investigators. I recommend that federal support be used to foster collaborative research by developing post doctoral research fellowships for complementary medicine trainees and by encouraging faculty appointments for complementary medicine investigators at conventional academic medical centers. Thank you for hearing my opinions.

GORDON: Thank you very much. Jim Taylor.

TAYLOR: I'm Jim Taylor. I'm a pediatrician from the University of Washington. I rewrote my thing when I saw your signs because I figured I had to chop it down some, so please bear with me.

I actually think we are in a very unique position for CAM research here in Seattle because there are located two large institutions with different approaches to health care, the University of Washington with excellent schools of public health and medicine, and Bastyr University, with Bastyr University Research Institute. The chance for collaboration between these two institutions and other places where there are such dual institutions is really unlimited. I think collaborative studies like this, or efforts like these would have enormous, would be enormously attractive to potential funders. And in fact, we've already had success. The reason I'm here today is because I'm part of a group of researchers from the University of Washington and Bastyr and private pediatricians in Seattle who were awarded an NIH grant for randomized control trial for the use of echinacea for treatment of colds in children.

In addition to lots of researchers with different areas of expertise here in Seattle, there is a high level of interest in CAM. In planning our study, we surveyed 600 parents whose children were being seen by private pediatricians. One-third of these parents indicated that they had given their child echinacea for treatment of cold in the past, and 53 percent had used at least one of the following therapies. These include herbal remedies, zinc, homeopathy, chiropractic adjustment, acupuncture, or massage therapy.

This interest in CAM has really been translated into participation in the study. In the first seven weeks of enrollment, a hundred children had been recruited from private pediatricians' offices and 45 from Bastyr University clinics. So we have researchers from many disciplines, we have a population willing to participate, and there are monies available for studies. So why has the collaboration been limited so far. And I thought of four things.

1. First is the lack of familiarity of alternative research and investigators by allopathic researchers.

2. Second is a suspicion of CAM therapies by allopathic practitioners. In my field, pediatrics, most of the research in the past is focused on the rare life threatening illnesses. A lot of CAM therapies, as you know, are helpful in relieving symptoms, so there needs to be a change of focus by pediatric researchers.

3. And last and most important probably, is in the past there has been a mistrust of practitioners and researchers from different disciplines.

I don't think any of these obstacles are insurmountable at all. There are too many positives to collaboration for future studies. And I would suggest that collaboration between allopathic clinician and researchers and CAM clinicians and researchers that include lots of patients from different areas is likely to have the most significant impact. This collaboration will result in the highest qualities of studies on CAM therapies, and maybe more importantly, the participation of allopathic researchers and CAM studies will facilitate the incorporation of CAM therapies with demonstrated benefit into the clinical practice of allopathic physicians.

GORDON: Thank you very much. The final speaker on this panel will be Karen Sherman.

SHERMAN: I'm Karen Sherman. I am an epidemiologist and also the Research Director at the Northwest Institute of Acupuncture and Oriental Medicine. I'm not an acupuncturist. My comments will focus on two important issues for the Commission. How can we use our limited resources to stimulate research on CAM practices, and secondly, how can we encourage CAM and conventional researchers to work together for mutual benefit?

Since CAM therapies are already being used by substantial numbers of the public, I think we should place relatively more emphasis on pragmatic clinical studies that examine CAM therapies as they're actually practiced, rather than the efficacy studies that are typically done of medications. If these effectiveness studies show that a CAM therapy yields good patient outcomes, then further studies can be done to find out which components of the intervention were responsible for its success, because it is true that CAM practitioners don't necessarily do the same thing, even when they see the same patient.

In addition, in the context of pilot projects in integrated care, which I do think are important, we can collect data on the safety of CAM therapies about which relatively little information exists and on some important patient outcomes for common medical complaints.

Performing rigorous research on CAM therapies is actually quite an intellectual challenge, even when collaborating with CAM practitioners as I do. I have experience in this area. I have been funded off of four grants, looking at these items, and also I've been involved in a couple of other studies. Often CAM practitioners are not well versed in research methodology. They may lack even very basic information that it would be necessary to construct protocols, such as how long the intervention should last and how often they should be given, or at least what the bounds of the limits on that are. I recommend that funding be available to help develop a research culture among CAM providers that would include monies for the development of rigorous courses on research methods in CAM institutions. I've been teaching acupuncture students research design for five years, and more needs to be done in that area.

In addition, conventional researchers need a better appreciation of how CAM is actually practiced so that they can think creatively and appropriately about designing such studies. The development of researchers who specialize in CAM methodology, people who would be familiar with the unique issues is also important. CAM research should based on what practitioners actually do. If we don't know, we need to ask them or perform surveys to find out. Most funded CAM grants, with the possible exception of studies of single herbs, have CAM practitioners listed as coinvestigators or practitioners, but often they're not really true collaborators, and that needs to change.

In summary, I think we should shift our emphasis on CAM research towards: 1) performing pragmatic clinical trials from the realm of health services; 2) in cross educating CAM providers and conventional researchers about each other's disciplines so that they are capable of collaborating with each other; and 3) in requiring clear evidence of real collaboration in preparation of grant applications. Thank you. GORDON: Thank you. And thank you all four for your grace with the time constraints. Joe, do you want to begin?

Questions from Commissioners

MAN: Dr. Taylor, thank you for your comments. I wanted to ask you how this would play out at the University of Washington. We hear a lot about collaboration and the need to synergize between the traditional and the CAM providers to do the kind of research that you describe. How would it play out at your university if the federal government, say, suggested that for you to be eligible as an institution to get federal funding a certain percentage of your work would need to be done with CAM providers? In other words, here you and Bastyr have a wonderful relationship. But what about all the other institutions where that relationship hasn't developed? How do you think that would play out in the dean's office?

TAYLOR: You're asking someone who is so far down from the dean that I have no idea what the dean thinks about. And without trying to be cute, I think it depends on, I think that would be very controversial. But I think it comes down to how much money is available and how much they need the money. If they need the money enough they would sort of make accommodations for that. But I would think before that people would suggest alternative ways to try to do that other than say you have to meet some quota.

MAN: Or just to leverage. In other words, there are certain research arenas where it would make sense to collaborate, and ways to fiscally promote that collaboration seems to be something we might want to think about. Can I ask a real quick question of . . .

MAN: . . .

MAN: Thank you. I really want to ask Dr. Mootz a question about the National Library of Medicine database and indexing of journals. And they use generally index medicases(sp?) the criteria. Is there a comparable gold standard for quality journals, not all medical journals are in . . . what other CAM journals would reach that threshold?

MOOTZ: Well, actually there are many CAM journals that are of similar quality to conventional journals that are in there. But NLM has pretty much limited it to one chiropractic journal. There is a couple of alternative health care journals that are indexed now. So to be blunt, it's relatively biased. I'm an editor of a chiropractic journal and we applied for indexing and it was turned down as irrelevant to chiropractic practitioners, yet it's probably the most comprehensive description of clinical practice activity of chiropractors. And the same has happened with three other chiropractic journals I know of. There have been some acupuncture journals I'm aware of that similar sorts of things have happened. And it's because the reviewers have no idea of the relevance or what it means. Having chiropractors and other CAM providers on the organizations would help solve that. NIH has one chiropractor now.

MAN: I have a question for Dr. Sherman regarding research of acupuncture. You understand that NIH funding the clinical trial using double blind study to treat arthritis knee, treat fibromyalgia, and other conditions. Do you have a better idea to design a study which could be convincing scientists, and also satisfy CAM providers.

SHERMAN: Well, I actually think that we will probably need to do a couple of these efficacy studies. It's impossible to have a completely double blind acupuncture study, but they're doing as well as they can. It's probably necessary to do that to satisfy the scientists. But from a pragmatic perspective, I'd like to see some of these pragmatic trials that use the designs from health services first. Then if we find something there, then we can start to take the intervention apart. But I do think there are probably a few special cases for acupuncture where it's perfectly reasonable to do that quasi double blind study.

WOMAN: . . . Question to Dr. Mootz . . . direction of the Department of Labor and Industry. I understand there have been discussions about incorporating an . . . old model for participating doctors and so with a concern about access to the public for chiropractic, I'm wondering what you have to say on the issue of the managed care organization model as opposed to open access to every licensed chiropractor in the state.

MOOTZ: I think with the Department of Labor and Industry's patient choice and open access is a given. There is nothing on the radar screen about limiting access in any way, shape, or form. Patient choice is key to all of our policy right now. The physicians who can treat as attending doctors in our system are delineated in in WAC(sp?), in regulatory laws. So that's not going to change.

WOMAN: I hear CAM being referred a lot to as CAM therapies. And our concern with CAM is on a quality of life and health promotion. A great deal of it is on. Can any of you say something to that? Do you have research on what makes good health, instead of focusing on disease? Or your research is based on what money is available, and there isn't money available for studying on what keeps you well. In China we say that the doctor keeps a client well, and otherwise they're not a good doctor. So could you.

SHERMAN: We were actually beginning a study where we're hoping to take a look at some of the outcome measures that CAM providers feel are particularly important and look more broadly. But among the published literature that I've looked at for general health related quality of life, you're not really talking about optimal health. There's one called a ceiling effect, and beyond that you're not really going to measuring anything. So your points are very well taken.

LOW DOG: Kathleen, I think, from NCM. I am very sensitive to the question about postgraduate training, because it's been raised actually in some of the states where naturopaths have applied for licensure that there isn't this postgraduate training, which even many of your own naturopaths feel has put you at a little bit of a disadvantage because you just don't get to see the volume of patients. But what would you see as the, what type of postgraduate training? Would you see it, like as a family, three months of surgery, six months of pedes, six months of obgy? Is that what you're looking for? What is your dream of postgraduate? And how does that best, how can that be done and what should it involve? DOWNEY: National College has become certified, has a certified residency program, this past year, through the . . . and the requirements for that residency program is that we have 60 percent of it is involved with a naturopathic doctor and 40 percent of it can be rotations with other practitioners of allopathic, well, mostly allopathic. That's how it goes in hospitals and things like that. Our ideal is, we have 23 residencies right now that are certified through our school. I'm now the director of that program. I'd like to see that double this year. And we're looking at all sorts of programs that would be collaborating with hospitals so that our residents can work in various rotations. In Portland we're doing that as well. We have all of our residents rotating in different disciplines. So it would be more of a broad-based discipline, like you say. It wouldn't really include a lot of surgery, since we don't do surgery, but minor surgery, gynecology, pediatrics, dermatology, cardiology; all those disciplines and have rotations in those.

LOW DOG: So right now is it primarily that they go out and like apprentice with a naturopathic

physician? Which is a good way to do it too. Is that what you're talking about?

DOWNEY: We have distant rotations. We have one, we have a couple with the Cancer Treatment Centers of America, we have six of them that are with our school, in our clinics, we have 16 community clinics, so they work with our naturopathic doctors in our community clinics in Portland. We have them with private physicians. So there is a lot of difference. And there are some that are working, there is one that is working in a clinic in Bridgeport, Connecticut, that is also collaborating with a hospital there, Griffin Hospital there. So it's a broad mixture of different types of residency programs.

GORDON: Tieraona, thank you for your question. And could you give us both a description of the residency and also a description of what you would like it to grow into, in writing. So what I'm saying is a description of the options that are available now, the rationale, and then your sense of how it ought to expand. Because I think that's a really good question and it would be very helpful to us. Tom.

MAN: Dr. Taylor, we've been hearing a theme that alternative practitioners need help applying for research grants, research protocols and so on. I'm wondering how the collaboration was effective and successful with the pediatricians and the alternative practitioners in your case. What was each bringing to the party? Is there anything that we can learn from your experience in what each professional was bringing to the collaboration?

TAYLOR: Basically I think our collaboration went really easily because of our situation. I think what the private pediatricians who participated in the study, what they brought is a real world view of what it's like dealing with patients all the time, having people ask them about these therapies, and they have no idea of either the names or what they do. So they brought that kind of focus to the group. I think for me working with the people at Bastyr, it was really an understanding, sort of, the basic science research on something like echinacea, and I think what I really had to offer was just sort of a pragmatic approach to doing a research study in a clinical setting like that. So I don't know if I really answered your question or not, but it really was very easy. And I think, I don't know about the other people, but I've learned a fantastic amount in this, and I know the pediatricians have. I'm not so sure the people at Bastyr have learned as much as I have, but hopefully they learned a little bit.

GORDON: Thank you. One of the things that would be helpful, too, both from your side, maybe if there would be some kind of joint statement that Bastyr and U of W could make about what kind of research training you see is useful. Again, you have a good history of collaboration, that's probably longer than most places, and the lessons you've learned spelled in writing for us would be very helpful as we think through some of these issues we come back to research.

Thank you very much. We'll move into the next panel now. And the first speaker will be Suzanne Myer.

Speakers

MYER: Hi. I am an Assistant Professor at Bastyr University. I am teaching in the largest nutrition program in the state of Washington. I am also I think the only registered dietician that will be speaking to you today or tomorrow. I had been trained as a clinician and as a teacher. I have not been trained as a researcher. I would like to be more involved in research as a clinician, but as previous speakers have talked about, there are limitations in my skills and knowledge, and then in resources to help with me being involved in research.

Also, as others have recommended, I echo the recommendation on more outcomes oriented research, especially in the field of nutrition. I think it's very difficult in the field of nutrition to tease out what is actually causing a benefit. Like we know the vegetarian diets decrease heart disease, but we really don't know why. So outcomes research is very very important.

And then also as has been previously discussed, funding is crucial, especially in the field of nutrition, when we're talking about real food, whole foods. And I'm often asked, what is a whole food. And if you can think of it growing, that's a whole food. Marshmallows, you can't kind of see a field of it growing. So if you can think of it growing, that's a whole food. And unfortunately whole foods don't have a lot of deep pocket funders and lobbyists to go after research funds.

But really what I wanted to do was give you a clinician's viewpoint on why research is important. I think food is incredibly powerful, and I particularly want to help my students help their patients prevent chronic disease, treat their symptoms, keep them from having to spend a lot of money on costly medications. We have a clinic in Wallingford, and where I supervise students, and a few years ago a twelve-year-old boy came in with his mother, and his mother wanted to not increase his asthma medication. So she said, well, let's try food and see if food has anything to do with your symptoms. So the boy came in a little reluctantly, but I have kids so I worked with him pretty well. He followed a ten day elimination diet that we used to test food sensitivities. He came back after ten days and told him mom and I that for the first time he ran after his dog without wheezing. And tears were in my eye. We figured out that he was sensitive to corn products, processed corn products, like in pop and candy. He changed his diet. He decreased the use of his costly medication and I think most importantly he figured out the connection between health and what he's putting into his food. I think diet is incredibly important and I would like to see more research put into nutrition. Thank you.

GORDON: Thank you very much. Is Jacqueline Obando in the audience? She has a place on this panel if she is. Okay. William Lafferty.

LAFFERTY: I am as Associate Professor at the University of Washington Health Services.

We look primarily at cost, access, and quality of health care in the United States. And I really think it's important to recognize that we have so many issues with health care in the U.S. right now. For example, the Health Care Financing Administration estimates we're going to be spending over 17 percent of the gross domestic product on health care by the year 2007. Forty-two percent of the worldwide health care dollar is spent in this country, and we still have over 15 percent of the people who have no health insurance. We have so many incredible gaps. The integration of CAM is merely one in a very long list of issues that the United States is grappling with right now.

I was thrilled by your question about what creates health. The School of Public Health and Community Medicine feels that the most important determinates of health probably aren't medical care, either alternative or complementary. It's income, it's equal access to jobs, it's good education, it's good food, the ability to buy the good food that you're talking about. And I just feel that whole social context is so important in all of these discussions.

With that said, I'd like to talk a little bit about money. The question was, for me, what do we need to get the private community to involve itself more in CAM research. And I believe it really is this whole area of cost effectiveness. Because if a private insurance company sees CAM as primarily an add-on being used by sick people with really no trade off as far as cost effectiveness, it's really not going to be very attractive for them to do anything more than just prove that. If, however, there are areas of medical care where CAM not only improves quality but lowers costs, I think there would be a tremendous amount of private excitement about it. And I think what you just heard is maybe one example, the ability to dump expensive medications, higher quality of life, and all of that. But the point being is, all of this research is truly in its infancy right now. And nobody knows what is what.

Well, in Washington state we do have a unique opportunity. We license CAM providers and we have mandated insurance funding for many CAM services. And at the end of this year all of that will have been in place for 12 months. And so I think we need to take a deep breath, look at what we've spent on CAM services with our state law, through our mandated insurance benefits, see what it looks like, and then thoughtfully try to make some decisions about where we go from there, were we sort of see the immediate results from what we've already done. And I think that will be very helpful. And I think there are lots of other areas when you're talking about cost, access, and quality that are so important to look at in the context of what are our overall health care priorities. But I think we need bigger data, more data, and better data upon which to make these decisions. So I just urge you all to speak for the voice of collecting very good scientific and economic data on these issues.

GORDON: Thank you very much. Charles Simpson.

SIMPSON: Hi. I'm Chuck Simpson. I'm the Chief Medical Officer of Complementary Healthcare Plans down in Portland, Oregon. I suspect that you all have had it up to here with collaboration and partnership and are thinking more about lunch at this point, but I would like to offer you my comments in writing and just basically skip to the bottom line about something that I haven't heard here yet this morning, and that is the potential for partnership and collaboration between the research community, the CAM professions and those who help pay the bills.

My company basically contracts with health plans in my area. And I would like to point out that there's a big difference between Oregon and Washington. We're not just the state that's between Seattle and Northern California. We have little different approach to integration of CAM into health care. In Oregon it is entirely market driven. There are no mandates. There are no legislative issues that are pushing CAM integration. It is all being done as a result of people making business decisions. And so that kind of brings me to my point, which is, and you've heard this from other folks, we really need to be developing the kinds of information that helps folks who do make health care coverage decisions, and despite all of the comments about public health, a whole bunch of us get our health care through the folks that we work for. The people that make those kinds of coverage decisions need some very explicit and pragmatic kinds of information about CAM and any other kind of health care, incidentally, when they're deciding what they're going to offer their workers in the way of health insurance benefits.

So my message to you is we need to help worker on figuring ways to improve collaboration among the payers, the research community, and the professions. And I would offer you one example in the Building Bridges model of not the local Building Bridges, but the Building Bridges model that was developed by the American Association of Health Plans and AHRQ that does exactly that. I think that may be a model that may be useful for integrating companies like mine with the broader research community.

And just as a side note, my company has a research relationship with Center for Health Research, which is the Kaiser Foundation research entity in Portland, and we have begun doing some very interesting kinds of work to address the questions of, are we looking at an add on or are we looking at a replacement cost when it comes to using CAM services. And what we're finding is it isn't just necessarily a measure of looking at the dollars spent on CAM on the one hand and looking at the dollars spent on medical costs on the other and deciding that yes, in fact, these dollars offset those dollars. What we're finding is that a dollar spent here really does not equate to a dollar spent there, and the analysis needs to be much more sophisticated. And so we're going down the road at this point of using conjoint analysis which, I've got to tell you I know nothing about, but it's a different way of approaching that very problem.

GORDON: Thank you very much. I have a feeling there are going to be some questions here. Tom, do you want to begin?

CHAPPELL: Yes. Mr. Simpson, could you speak about the motivation that the private carriers have for understanding and incorporating CAM services. Where are we in that regard? That is, risk management decision based making versus wellness providing services.

SIMPSON: I would look at it in two ways. One is that the health plans are responding to the market in my community. Basically Kaiser was hearing over and over again from their customers, bring us, the were starting with chiropractic, and that's where they started. Turning around, however, the health plans didn't know where to go. Didn't know anything about CAM. They had to turn to organizations like mine to help them figure out how to integrate CAM with the typical medical kinds of models that they had already in their system. They're real comfortable integrating the medical side, they just don't know enough about CAM to do that.

WOMAN: For Dr. Simpson. Part of our real life here, I know that CHP is attempting to make inroads into Washington state with Regions Healthcare and as Regions providers, our office already got a letter saying it was their intent to reduce the participating providers by 80 percent. So with access being my issue, I would like you to address how your third-party administration is going to improve access to chiropractic for Regions subscribers.

SIMPSON: I'm not quite sure what that has to do with my presentation here, but I'll have a swing at it. You heard about the issues of cost, access, and quality, and you also heard from the OIC that they will be holding the local health plans to access standards. The only thing I can say is we will meet those standards.

WOMAN: Thank you.

GORDON: I have a lot of questions. And my questions are really asking you, because what you've touched on in terms of the models of how you understand whether a dollar here equals a dollar there and how do you understand the integration of different kinds of therapies, I would like you, if you have or are in the process of developing those models, to make them available. If you're going slowly, please go a little faster. Because our charge is to present exactly this kind of information to Secretary Shalala, to whoever is going to be the Secretary of HHS, to the White House and to Congress. And the sooner we have your best understanding of how this financing could work or is working, and especially how it should work based on how it could and is working, the better, from our point of view. So this is really, in the nature of our collaboration with you, we need your help. We need you to do take a look at the natural experiments that are going on and to tell us what's going on and then to give us direction in how you think it should go. And as best you can, drawing on the different models that you have available, to give us a sense of what it's going to cost to provide what to people. Just to share with all of you, as we have had our hearings in Washington, as we've been in San Francisco and here, and as we look forward to the next hearing on access and delivery back in Washington, we're working toward that bottom line question. So please help us.

Maybe everybody is hungry. You have one question. Go ahead Linnea.

LARSON: Just a real quick question. You're Dr. Lafferty. You said, and correct me, that we need bigger, more, and better data both in economic and scientific information before we make decisions. Is that the implication? Or is that?

LAFFERTY: I think we need to look, in Washington state, for example, I think we need to look at the decisions we've already made and evaluate available data, for example, at the end of this year, with the very large samples that we've got from the private insurance companies. That's primarily what I was referring to. And you're talking about 12 million claims over per company per year that we've never looked at anything quite on that scale has been applied to this particular issue. So I think when you're trying to balance priorities, you ought to have everything in front of you that you possibly can. And that's really all my comment is speaking to.

LARSON: But in way by implication, it's let's look at the data that generated out of the Washington experiment, and thereby apply that model to whatever we're looking at federally?

LAFFERTY: Well, I don't know if it'll apply to the federal model. It may in some respects. For example, you know, because at the federal level, Congress is continually debating patient bill of rights and can you really expand a patient bill of rights without including CAM in all fairness? That's what happened at our state level. How can you self-refer to every allopathic specialist and get that in law and not include this whole other segment of health care provides. So I think the issue does come up. And it's going to come up over and over and over again and really warrants some very in depth look. And I'm not wise enough to know how all of this is going to work out.

GORDON: I think the question we're really asking you is to use whatever wisdom you have to tell us how you think it should work out in a way that would be reasonable, coherent, and provide the kind of health care that people need. So we know it's a big challenge. We need all the help we can get.

Speaking of help we can get, we're going to adjourn now. We'll come back at 1:30. For the first session a couple of us have a, we're going to a cable TV, Council cable TV, so Dr. Joe Fins will be chairing the first session after we get back which will start at 1:30. So we'll see you all then and thank you very much.