WOMAN: Welcome back. I hope you all had a good lunch. Dr. Gordon and several of our commissioners are doing a brief television spot right now. They'll be back and joining us shortly. But we would like to go ahead and get started so that we can finish on time. If we could please have Arlene Darby begin.

Speakers

DARBY: I'm Arlene Darby of Bellevue. I've been a participant, as well as an advocate for, CAM. When I say "complementary," I mean "conventional" is in with that. Praise for each one, including President Clinton, plus all who inspired him, who were involved in any way to make the White House Commission on CAM possible. Praise for the professionals and all participants who are and will be a part of the paradigm shift called CAM. When a paradigm shift occurs, it brings about the challenge of change, and often some chaos occurs before one can celebrate the change and paradigm shift. Some participants here today have found themselves not only working to bring about the greatest degree of health possible, or at least the best quality of life under the circumstances, but also are participating in the process of defending their practitioners. Protocol, standard of care, is often a problem. Updating protocol is a basic premise to the shift of the paradigm in health care. Pushes and pulls of political forces -- not just government, but other political forces -- is a reality. With pen in hand and paper -- legal documents, that is -- the power base in Olympia and other states, plus the political strategy, strength, and support of the power in Washington, D.C., CAM can become legal.

What potential is possible if practitioners and patients could only talk to each other about all possible facets of care! Pecuniary or money matters are very powerful, perhaps more powerful than political powers. Actually, pecuniary matters and political powers are intertwined. All participants for CAM will need miraculous negotiating skills, skills as awesome as those of people who have done the impossible in every field of endeavor throughout history. Planes -- Boeing, that is -- and Microsoft, along with the whole high-tech field, have given people, projects, programs, and products an opportunity to be all over the world. However, people, projects, programs, and products have also arrived here. Included are cultural differences in health care. CAM is a part of this.

Again, praise for all the leaders in the Puget Sound area and beyond for their vision, persistence, and perseverance in pursuing the challenge of the paradigm shift in healing and health care so that safe and effective CAM therapy will be made legal. Please pursue all efforts on behalf of making CAM possible and legal.

May I hold up one other praise? Our natural medicine clinic in Kent was on The Today Show in 1997, the week they did a feature each day on alternative health care.

Thank you.

WOMAN: Thank you. Nicole Ellis? Is Nicole Ellis at the podium? Rose?

ENG-LUM: Thank you. We have all come back from lunch, and some of us may be a little sleepy. In Chinese medicine, we would call that spleen deficiency, wouldn't we?

My name is Rose Eng-Lum. I represent Dai Wai Association. I'm the founder and the president. We are a very unique organization in that we are trying to apply integrative medicine, a holistic approach -- that the mind and the body and the spirit absolutely must be integrated for people to have wellness. We focus this information in the area of a societal problem, and that is suicide for youth, and also for other sort of closed conditions in society that lead to disease. In those areas, we talk about domestic violence, sexual abuse, sexual orientation, in view of trying to help the community understand that when individuals are totally integrated, they do not then have a reason nor a will to do harm to themselves or to others.

A secondary issue I would like to address is that of, hopefully, alternative and complementary medicine will make its way into the public-health clinics and be available for migrant workers and for individuals whom we may call disadvantaged populations. Environmental studies have shown that people who are exposed to pesticides, herbicides -- some of this huge degradation of the earth for the sake of productivity has done great harm to people's health. In public testimony, individuals have stood up and talked about how only alternative medicine can help them.

Therefore, I feel we owe it to them to search our souls, to be able to implement this type of practice and make it available for those individuals who cannot be here today or have a voice.

Thank you.

WOMAN: Thank you. Bruce Milliman?

MILLIMAN: My name is Bruce Milliman. During my tenure as president of the Washington Association of Naturopathic Physicians, the all-category law came into force and mandated, as you've already heard, that all health-insurance plans provide relatively unfettered access to all categories of licensed care. In 1995 and 1996 of that year, I was invited to meet with the medical directors of several health plans in our state to propose how my profession might be included in third-party reimbursement. I stated that, as we were qualified and trained in fully accredited naturopathic medical schools, as we were required to pass state-administered naturopathic medical boards and were licensed and regulated the state of Washington and were accessible to malpractice insurance, and also that as we were designated as primary-care providers by our state secretary of health, we should be incorporated into the various reimbursement plans marketed by the health-insurance companies on a level playing field with conventional providers.

I further recommended specifically, number one, that we have direct access by patient choice to naturopathic medical services, and number two, that reimbursement for those services be equal to conventional medical reimbursement.

We have achieved these goals in the state of Washington with two of the largest health plans. However, other major health plans have created obstacles for patients to care and to equal reimbursement, in four ways: Number one, by limiting patient access to care to a restricted number or list of diagnoses; number two, by limiting patient access to services rendered to an amount not to exceed a specific dollar cap; number three, by limiting access to care by a requirement that the patient must be referred to care by a conventional medical provider; and number four, by limiting patient access to a narrow panel of providers.

The naturopathic primary-care physician model in which, as a licensed profession, we have been schooled continuously for nearly a century has been popular, efficacious, and cost-effective here in the Northwest. It should be replicated throughout the United States. Additionally, all licensed, accredited CAM services should be reimbursable by all federally funded programs. CAM services should be required to be delivered by providers degreed in said accredited CAM programs. Funding should be available to form CAM peer-review committees throughout the country. Funding should be made available to assure access to residency training and loan reimbursement for all CAM professions.

Naturopathic physicians are a national treasure, especially as our population is aging, and should be part of the solution set to heal an ailing nation and an ailing national health-care system.

Thank you.

WOMAN: Thank you. Jayne Leet?

LEET: Honorable Chair and Honorable Commission Members, my name is Jayne Leet. I have a degree in social work and an MBA in health-care management, with thirty-two years' experience in community health programs. I currently own and operate a licensed adult family home, providing twenty-four-hour care to frail elderly.

My remarks about access to CAM providers are the result of my experience as a CEO of the Community Health Centers of King County at the time of its implementation of the first publicly funded CAM program in the country, as well as my own experience as a consumer diagnosed with a very aggressive form of breast cancer in July of 1995, who decided not to undergo the usual standard of surgery, radiation, and chemotherapy.

Due to the lack of time, I will quickly list my recommendations for consideration for policy: One, require medical insurance carriers to offer access to licensed CAM providers within all coverage plans, and not just their most expensive. Two, require the same of federal Medicare programs and state Medicaid programs. Require medical insurance carriers to allow for consultations and second opinions by licensed CAM providers. Again, the same requirements for Medicare and Medicaid. Three, require insurance companies to allow for coverage for non-prescription substances prescribed by a licensed provider and certified by that provider as a primary required component of a treatment plan chosen by the consumer with informed consent. Again, the same for Medicare and Medicaid.

Examples in our community health center: We found good results with garlic-melon ear drops for otitis media. Low-income individuals on Medicaid would not choose this option due to lack of coverage under Medicaid. They would continue to choose covered antibiotics even when ineffective and a lesser choice.

My own example was, I elected not to go with radiation/chemotherapy, which would have cost tens of thousands of dollars, but instead went with a much lower-cost but totally out-of-pocket cost, based on detox, pancreatic enzymes, and supplements. My comprehensive insurance program covered nothing except a basic doctor's office visit.

I see very few insurance companies represented on the speaking panels. I hope efforts will be made to ask them what it would take to get them interested in coverage in CAM, through some sort of survey or special programs. Perhaps government incentives should be offered to insurance companies for long-term studies regarding the cost and outcome of utilization of CAM providers and natural supplements. In addition, medical-coverage insurance companies could offer a partial cash-out of annual or maximum insurance coverage for those patients with catastrophic or terminal illnesses who choose, through written informed consent, other options. This is currently done with life-insurance companies.

I would like to see this Commission assess the regulations and means by which state boards of health and federal regulators can dismantle practices and remove licenses of providers practicing in the CAM realm. In many instances, two to four MDs, not even of the same specialty, have been able to strip MDs utilizing, quote, non-standards of care, unquote, of their licenses. It would be very beneficial to access if the Commission could be instrumental in revamping the narrow constraints dictated under the rubric, quote, standards of care, unquote; instead, promote the incorporation and integration of CAM treatment modalities through which wider use of informed consent could be utilized.

I would also like the Commission to support the integration of CAM providers within the community-health-center network across the country, to serve low-income, elderly, and ethnic minorities. It has proven a success in this region.

Thank you very much for this opportunity.

WOMAN: Thank you. Before we start our questions, we would just like to let you know that insurance companies were asked to come and participate, but did decline. If any of you are present, we certainly would encourage you to submit your comments, since there has been a lot of reference to you.

Dr. Tian, start questions, please.

Questions from Commissioners

TIAN: So how do we do a survey for the insurance coverage? You want to give a grant to insurance companies or some scientific people to do the job, or a CAM provider can do the job?

LEET: I guess I would hope that there could either be grants or some other form of incentives that would encourage them to do studies. When I have talked with insurance companies, the response I always get back is, if they incorporate CAM providers, then it will be a higher cost because people won't choose either/or; they'll choose both. My response to them has been, so what? I think, in the long run, you will find that the cost of coverage may be lower. That's a long, long run, in terms of preventive. Certainly in terms of cancer, where more and more people are seeking other alternatives, I think there could be studies that would show that the cost is lower. But they seem to be very fearful of opening that up because people would tend to choose both, and the cost would be higher.

CHOW: I'm also directing a question to you. Your decision to use CAM therapy instead of Western medical approaches -- was money the main factor?

LEET: Oh, no. It would have been far cheaper for me to have my insurance coverage pay for the traditional methods. I had a sister die of breast cancer who went through the chemotherapy and the mastectomy programs. It was purely a belief system on my own part. Being involved in the health-care system, I certainly had several MDs who came to me and told me I was making a terrible mistake. I will say that it was truly an integrated program. Before I made my decision, I did avail myself of a breast MRI to see how extensive it was, before I made a decision not even to have lymph nodes removed. I did do a lumpectomy, but I did not do the suggested mastectomy. I did seek out several providers, and I sought out MD providers and oncologists that would be supportive of my decision to see natural medicine. But certainly the cost to me was far more than it would have been if I had had my insurance company cover the traditional method. If my insurance company had been willing to pay for what I chose to do, it would have been far cheaper to them than the cost of the chemotherapy and the surgery and the radiation.

CHOW: But you made an informed choice.

LEET: I made an informed choice.

CHOW: This is important.

LEET: It's very difficult to make that informed choice, however. I also had several MDs tell me they were afraid to support my efforts, especially with an oncologist who at the time was basically in the process of having his license removed from the board of health, and, though several of them said they wanted to come to that provider's support, refused to do so for fear of their own license.

WOMAN: I have a question for Dr. Milliman. There have been a lot of questions about whether Western medical providers sort of be co-opting many of the complementary therapies ?? learn a little manipulation, learn a little acupuncture, learn a little herbs. There has been some critique that that's not really practicing within the paradigm that those systems often include, whole systems. Are there holes in your training that you think Western practitioners or Western-trained physicians -- because I'm hearing about limited diagnosis, referral by conventional medical doctors -- are there areas that you think Western providers may be better at addressing and certain areas that naturopathic physicians would be better at addressing? Sometimes I see that there's a little blurriness, because naturopathic training is very similar to Western medical training, in some regards, with basic medical science, but then treatment varies. Do you hear what I'm saying?

MILLIMAN: Yes. I think that if we look at the Western medical paradigm and think of the division of medical specialties into specialties and subspecialties, if a family practitioner were to come across a very complex cardiovascular problem, they would undoubtedly refer that person to a cardiologist, and so on; similarly in our arena, if some of the individual therapies can be applied, probably even in a not harmful and very helpful way by conventional medical practitioners, who may have weekend seminars or other kinds of training in alternative therapies. But, ultimately, if somebody is going to be treated in a whole-person system, whether it's Chinese, Oriental, medicine, acupuncture, or herbal medicine, naturopathic medicine, et cetera, they would need to see somebody who, as I alluded to in my remarks, was actually qualified in a degreed program; their educational training had risen to a licensable level of qualification -- just as if, again, a general practitioner in the conventional arena were to perform brain surgery. Even though it's technically within their license to do surgery, it would be medically irresponsible and nobody would sit still for it; the disciplinary board would be down on it. It's exactly the same. It's a very clear model we have.

WOMAN: The other part of that question was, at least in my state, in New Mexico, part of the issue of primary care and naturopathic physicians has been the question, are naturopathic physicians trained to be able to make the diagnosis of a patient coming into the clinic. Have you seen enough patients to be able to recognize a complicated cardiac patient for referral? This is a question that comes up all the time. I'm just asking -- you've been through the training -- what do you feel the level of training is, and expertise? Are there areas that Western providers should be seeing, versus naturopaths?

MILLIMAN: If you're talking about in terms of triage, if a person comes to a primary-care setting, whether they come to a primary-care osteopathic physician, naturopathic physician, medical doctor, or ARMP, or midwife, if that person is trained, licensed in a qualified training setting, in a fully accredited school and is practicing -- they're actually in practice -- they're absolutely qualified to triage: Does this person need to go to a cardiologist or can I manage their level of hypertension or cardiovascular disease in-house? Any one of those licensed, and licensable and credential-able, provider groups could make that decision responsibly, safely, and, undoubtedly, effectively.

MAN: Ms. Leet, I apologize for missing your testimony. I did hear a little of it. I was wondering if you could perhaps comment on the relationship, if you've had any experience with hospice activities and CAM.

LEET: Only to the extent that, as now an owner of an adult family home, where we care for frail elderly, we have had the opportunity of taking care of hospice patients, as well as very frail stroke patients, diabetics, et cetera. I can tell you that our efforts to work with conventional MDs in terms of being willing to prescribe any kind of natural remedies to help these people is very difficult and very intensive. But it has worked, and we have seen remarkable results for reduction of pain, for having people totally removed from insulin for diabetes, for people that had been diagnosed, for example, with Parkinson's, losing their tremors. For people with arthritis, which we see every day, I can't believe the number of doctors that still are unwilling to try something as simple as glucosamine products in terms of at least attempting to relieve some of that pain. We have seen men that are incontinent -- the use of saw palmetto.

Once conventional docs say the usual -- "okay, I guess it will do no harm" -- they are totally amazed at the results, and at least are more willing to prescribe that for other patients.

WOMAN: Any other questions? Thank you.

Now we have Daniel Labriola.

Speakers

LABRIOLA: Thank you. When I first started this journey twenty years ago, the White House couldn't even spell "complementary" with an "e," so I have to tell you, I am really happy to see you all here. I'm Dan Labriola. I'm a naturopathic physician. I practice in Washington -- well, maybe they could spell it. I didn't meet anybody who could.

What I'd like to do in the next 2.9 minutes is discuss how the delivery of CAM therapies in some jurisdictions, which are delivered in an inconsistent, if not incompetent, way, is affecting public safety, the public interest, and the hard work of this Commission. I'm also going to suggest some ways that the Commission can provide some leadership and guidance in this area, in my view.

Let me give you a little background, so you know where I form these positions. I'm a naturopathic doctor. I have been practicing for fifteen years. I'm a Bastyr graduate. I was one of the principal authors of the legislation that currently licenses naturopathic physicians in the state. I was the first ever special adviser to the Department of Health in the state for complementary and alternative medicine. I was the first chair of the governing body in this state within the Department of Health, called the Naturopathic Advisory Committee. I did that for almost ten years. I participated in other really exciting government initiatives, such as the health personnel resource plan, which you'll hear about. I currently direct the Northwest Natural Health Clinic. I am now also director of integrative care for a very large integrated cancer facility within the Yakima Valley Memorial Hospital System. It's called the North Star Cancer Center, which is a fully integrated, high-technology treatment center where naturopathic physicians and other CAM providers -- acupuncture, traditional Chinese medicine, et cetera -- will be coexisting and functioning in direct integration with conventional medical specialists -- a very exciting program. I've been doing this for a very long time. Actually, even as long as twelve or thirteen years ago, I was a consulting physician within the Fred Hutchinson Cancer Research Center, as a naturopathic physician.

In this time, and in the next fifty seconds, I can tell you that I've seen the best and I've seen the worst. I've seen outcomes that could never be accomplished by conventional medicine alone, because natural medicine was participating in a real and valuable way. I've also seen the very worst. I've seen morbidity, I've seen extreme side effects, and I've even seen deaths as a result of patients getting either bad advice from unlicensed or unlicensable providers, or just making simple mistakes on their own. I have seen enough to make you sick. I've seen teenagers, and others, just as a result of having done things incorrectly.

So there is a real need for this information to be provided in a real consistent and competent way. My request is that the Commission consider developing basic policy and encouraging jurisdictional licensure and enforcement and regulation to protect the public interest and take advantage of the leadership opportunity that you have to have this freedom of choice available throughout the United States and various jurisdictions where this licensure occurs. Washington State is an excellent model for people to look at. You are going to have a really great speaker later today, Bob Nicoloff, who's the executive director from the Department of Health for most of these.

Thank you.

WOMAN: Thank you. Everybody has so much to offer, we're sorry we don't have more time. Gay Koopman?

KOOPMAN: I'm speaking on behalf of access, delivery, and reimbursement for integrative care, focusing on the aspect of delivery. For my pregnancy, I chose my health-care provider as a licensed midwife, and a birth-center delivery was planned. However, after twenty-four hours of labor, a hospital transfer was done. At the hospital, the nurses were not willing to review the chart with the licensed midwife. They were resistant to hearing about the labor history from her or to allow her to continue to participate with my delivery. When the doctor arrived, the entire atmosphere changed, since there was already an established relationship between the doctor and the licensed midwife. Additionally, the nurses were, at times, bothered by the role and level of involvement of my labor coaches.

With more understanding, education, and respect for what licensed midwives do, this transition would have gone much more smoothly, for the nursing staff, but mostly for me and my daughter. For a few months after the birth of my daughter, all medical bills were mailed to me, some more than once, even after I contacted them with the correct information. The insurer expected me and the licensed midwife to know which insurance products the doctor was a preferred provider with, and that it wasn't enough that the doctor was a provider with their company. In the end, it was resolved, but if there were stronger relationships with all types of providers, insurers, and their practices, there would be less stress and confusion on behalf of their patients.

WOMAN: Thank you. Kathy McVay?

MCVAY: Good afternoon. I'm Kathy McVay, and I administer our state's loan repayment and scholarship program for health professionals. Our program was created in 1990 to address the critical issues of shortages for rural and urban underserved individuals in our state. You heard this morning something about our federal program. Our state program was created to mirror that federal program. I'll tell you that connection later.

First, I believe we are the only state in the nation that provides loan-repayment and scholarship support for CAM professions. Currently, our program includes naturopathic physicians and licensed midwives. The midwives are eligible to receive support from both scholarship and loan-repayment programs. However, due to lack of Medicaid/Medicare reimbursement for MDs, they are eligible for loan repayment only. Currently, we have two naturopathic physicians receiving support from the loan-repayment program.

The decision to exclude them from scholarship was based on lack of reimbursement for seeing a population which is required by the service obligation of the program. The lengthy debate by the program's advisory committee determined that the program could not be responsible for the economic viability, or lack of, for a provider with a commitment to serve the Medicare/Medicaid population. As a result, MDs are eligible for loan repayment until a time that the need in the communities outweighs our ability to assign them to the communities. At that point, when we determine that the economic viability for them would survive, they would then be able to receive scholarship, which commits them to an obligation when they're trained.

Second, as a result of this debate, the CAM professions have taken it upon themselves to create outreach and education to communities about their professions. Funding for that ongoing outreach is necessary in order for that to continue.

Third, if CAM providers were included in the National Health Service Corps Program, we, as recipients of federal dollars for state match, would be able to use those dollars across all of our professions that our state now supports.

In summary, we have a successful collaborative relationship among all health professions in Washington State. With more funding and fewer restrictions on reimbursements, that relationship will grow and be stronger.

Thank you.

WOMAN: Thank you. Effie, we'll start with you.

Questions From Commissioners

CHOW: I don't have any questions.

WOMAN: I didn't quite understand everything you said, so I just need you to give us a copy of it. I couldn't follow all of the details.

MAN: Dr. Labriola, your reputation precedes you. I was flying in yesterday to Seattle, and someone said, "Are you going to hear from Dr. Labriola?" I said, "Yes," because I had just looked through the agenda. So it's nice to meet you. Your reputation does precede you.

LABRIOLA: Thank you.

MAN: You were talking about bad outcomes, the worst and the best. Has the state developed any kind of tracking system to identify adverse outcomes from CAM practitioners that we could learn from, through the licensing process or requirements?

LABRIOLA: It's a very good question. Most of the bad outcomes are from people who are either not in the licensing process -- for example, in Washington, D.C., anybody can walk in off the street, with even a mail-order diploma, and get basically a registration that says, "I'm now a naturopathic doctor," put it up on the wall, and see people. They're not tracked very well. Where these get tracked is in malpractice actions that tend to be practicing medicine without a license. Others are in civil suits. Others are in criminal inquests, when the outcome is really, really bad.

I did review this about twelve years ago, when we were getting our licensure here. It's a long, extended job, but that's possible. It can be done. Many of these cases are documented elsewhere. Some of the cancer deaths that I've seen are actually published papers. So some of that data is available. It's kind of time-consuming, but it can be put together.

MAN: But that's a retrospective -- if I may ask a follow-up question, Madame Chairman -- we can look at it retrospectively if there's been an adverse event. But what if a practitioner -- I think there's an argument here for licensure, to teach people to report adverse events. If someone is not licensed and they're out of the system, they have an observation -- several patients have a certain kind of adverse response to an alternative therapy. What kind of training has been done to train CAM providers to know what to report, to identify trends, so we can track things prospectively, and not have to deal with the lawsuit or the inquest after the damage has already been done?

LABRIOLA: In a really good regulated environment, like Washington State, which is arguably among the best, we teach subjects such as drug-nutrient interactions, clinical diagnosis, clinical treatment, which you were talking to Dr. Milliman about before, to try to identify some of those interactions. Unfortunately, the interactions are not always identifiable. The patient comes in with dyspepsia, and the first thing you ask is not, "Are you taking an herb," the first thing you try to do is sort out if something else is going on. Oftentimes, these problems are multifactorial, where there may be a problem that's increased many-fold as a result of something that was done incorrectly in a CAM environment.

It's not an easy subject. But the state of Washington has been very proactive in its training requirements, at least for naturopathic physicians. I think we're going to be incorporating more of that with TCM and others. So there is a model.

WOMAN: Effie, did you have a question?

CHOW: Thank you for your presentation, and congratulations on all your firsts. There have been a lot of organizations referring to outcomes research in this discussion this morning. You said that you've had really outstanding outcomes research. Is that what I understand?

LABRIOLA: I've had wonderful experience. I've been doing this for fifteen years.

CHOW: They're large studies, are they?

LABRIOLA: There are not a lot of well constructed studies right now. There are some that are very good and valid, that provide us good information. The resources have never been there to really do more comprehensive studies, which I think need to be done. We know many of these therapies work, but we haven't put them into large national cohorts yet, which is something that needs to happen. But that takes research money.

CHOW: I hope that you'll do that soon, because your research data will be very helpful to us, in the sense that there is a big debate in the whole research area about the clinical trials and the double-blind studies and all that. Outcomes research and best-case series and field research is perhaps the appropriate area. It would be helpful if you could gather that for us, the data, as much as you have.

LABRIOLA: I'd be happy to continue this discussion. It's a pretty big subject we're talking about here. I agree with you completely. It's just critical that those resources be applied and that the people constructing these studies construct them in a way that we're getting really valid results and we're establishing controls -- which is not always an easy thing to do -- establishing crossover, and basically establishing scientific credibility here, so that it just can't be -- you know, what is, is, and what isn't, isn't. Oftentimes, because of lack of resources, we don't have enough available to us to really make these studies comprehensive. There are a lot of good ones out there. But I agree with you completely; we need to be putting more effort in this area.

CHOW: Again, we need good models now.

LABRIOLA: Yes, I agree completely.

WOMAN: One quick clarification, if you could, for the group. There are schools of naturopathy that you take the boards for. There are also mail-order naturopathic places that you can get naturopathic degrees from. Were you saying that here in Washington, if you've been through sort of a mail-order type of MD training, you can actually be licensed and reimbursed?

LABRIOLA: No. This was Washington, D.C. I don't know about reimbursement. No, no, no. Let me be very clear about that. Washington, D.C. -- the state of Idaho is another state where you can do this. I don't know about reimbursement. Actually, I understand that some of these people get reimbursed, which baffles me. I won't even start on that. It's not the only thing I've been baffled about over the years. But in Washington State, they run a pretty tight ship, and I don't know that anyone practicing outside of the legal system is reimbursed. There may be people who could give you a better answer to that.

WOMAN: Thank you.

WOMAN: I have a question for the Commission. You are looking for large batch studies that are done to clinical specifications that would pass double-blind testing conditions. Do you look seriously also at the literature where individual naturopathic doctors or practitioners of Chinese medicine and other practitioners in the alternative-care field -- do you look at the professional journals, at monographs and so forth, where someone has presented a case study and documented the treatment from beginning to end?

WOMAN: Thank you for the question. If you would submit that to us in writing, we'll be able to respond to you, but in this forum, we won't be able to answer your question.

WOMAN: My question is, do you honor those the same as you would aggregated data, large batch data from Bastyr University or other things like that?

WOMAN: I think we're looking at the whole range of information.

Okay, thank you. Let me call up the next group. Fred Bomonti, Laurence DeShields, Tracy Turner, John Huber. Also, if the following people can come up at the same time: Lawrence M. Jacobson, Laura Patton, Elizabeth Goldblatt, and JoAnne Myers-Cieko.

MAN: It's nice to be back. We were just meeting with the county council for a few moments, and felt very warmly received and bring back their greetings as well.

Fred Bomonti?

Speakers

BOMONTI: Thank you for the opportunity to speak today. My name is Fred Bomonti. I'm a chiropractor, and I've been in private practice for over thirty years. I had the good fortune -- or the bad fortune -- to be in training and begin practice as the AMA began its organized effort to, quote, contain and eliminate the chiropractic profession, unquote. I've been an observer of the assimilation of osteopathy by the allopathic profession and now the beginning assimilation of the other vitalistic professions, including my own.

To, quote, maximize the benefits to Americans of complementary and alternative medicine, end quote, it is important, in my opinion, that we understand that allopathic medicine and the so-called complementary and alternative, CAM, professions are not and cannot be considered by the same standards. They are two different paradigms of health care with a common focus. That focus: the health of a human being. Allopathic medicine has a history and a focus of treatment and prevention of disease by attacking the disease to preserve life. It is the offensive unit. Alternative medicine has a history and a focus of treating people, promoting health, to increase the quality and span of life. We could call it the defensive unit. Both viewpoints are valid and are the flip-side of each other. Both are necessary. Procedures of each can be used offensively or defensively. One is vitalistic, promoting the innate, inborn healing ability of the body, and one is atomistic, promoting the scientific imposition of treatment on the body.

For the past one hundred years, the mechanistic, atomistic philosophy of health care, represented by the allopathic profession, has been the dominant political force in America. It has ruthlessly attempted to stifle, crush, eliminate, assimilate, or destroy all opposing viewpoints for its own maintenance of power. These attempts continue today. Without acknowledging the political conflict of interest and the lack of objectivity brought by our various backgrounds of training, we will not get an objective analysis of the potential benefits of the so-called CAM professions. The focus will be on the atomistic philosophy remaining in power or, from the vitalistic side, what do I have to do to survive? Until we recognize that maximizing benefits to Americans or maximizing the health of people is our overall purpose, not perpetuating a particular political point of view, we will not be able to obtain those maximum benefits. In other words, the integration of members of the recognized accountable healing modalities on their terms into the mainstream health-care system can improve the individual health of human beings, and thus society. Assimilation of CAM proceedings by the members of the allopathic community and calling it alternative will do nothing but continue the present insanity we call health care, "insanity" being defined as doing the same thing over and over again, expecting a different result.

I believe it was Einstein who said the same mind that created the problem cannot solve the problem. It is incumbent upon all professions to focus on the person, not the method; the goal, health, not the one who gets the credit.

Considering that's the last minute, I'll let you read the rest of it yourself.

MAN: Thank you. Laurence DeShields.

DESHIELDS: Hi. I'm Laurence DeShields. I'm a consumer and a board member of the Community Health Centers of King County. My experiences were kind of vast, in that I've had problems for the last forty, fifty years, and have gone to physicians, in my travels. I traveled all around the world in my work before I retired. I still had the particular problem. When I was here in Washington, I decided to go to see the Community Health Centers, just as another alternative, just to see what would happen. I went to see a physician. The physician decided to get all my records. She actually got them from everywhere . . . in the United States and outside the United States. After she got all of these records, she asked me if I thought there was a solution. I said, "Well, it doesn't seem like it, in all these years." She said, "Are you open to alternative options?" Then I looked at the naturopathic medicine, and I looked at acupuncture. When I went to the naturopathic medicine, they took time and care and they were very patient. That was the first time I was ever in a doctor's office for an hour-and-a-half that they weren't doing surgery. They were trying to really understand and quiz me, to make sure they had all of the facts before they could go off.

The bottom line was, the result was that they came up with a homeopathic cure that has worked. I have not had the problem since.

Thank you.

MAN: Thank you very much. We appreciate it. Tracy Turner.

TURNER: Hello. I'm Tracy Turner. I wanted to give you my story as a patient, and how I've benefited from complementary and alternative therapies.

I'm a patient of Country Doctor Community Clinic here in Seattle, Washington. I was AIDS-diagnosed in March of 1995. I also suffer from grand mal seizures, as of mid-1996. I strongly support complementary and alternative medicine. After your review process, I hope you will decide for aggressive study and funding of CAM, which will allow patients more flexibility and alternatives in their health care.

The reasons I use complementary and alternative therapies is that I have such severe reactions to virtually every medication I try, so severe it took me over a year to get on my first anti-seizure drug or HIV medications. After utilizing these therapies, I'm proud to say I've been on them for three years.

Also I have chronic muscle pain caused by my seizures. The three therapies I utilize are acupuncture, massage, and chiropractic services. Acupuncture has by far helped the most in alleviating side effects from my medications, such as nausea, loss of appetite, pain and numbness caused by neuropathy, migraine headaches, chronic fatigue, rash, general feeling of ill health, just to name a few. Massage has also been very helpful in alleviating pain and numbness of my neuropathy. It has also reduced muscle pain caused by my seizures. It has given me an emotional well-being in order to more enable me to deal with my illness. Chiropractic services have also been of great benefit, helping with my grand mal seizures. After each seizure, I have severe neck and back pain that won't go away. I tried muscle relaxants and pain medications, and I either had great reactions to those or they weren't working very well at all. Chiropractic services, I'm proud to say, have made me to the point where I can live without back pain.

Two groups that can benefit most from complementary and alternative medications are those suffering from severe drug side effects -- it might entice people to stay on the regimens when otherwise they wouldn't. Sometimes the side effects of the medications are worse than the illness itself. Also it would give alternatives for people not responding well to medications, Western medications.

In closing, when making your final decisions on the subject, I hope you will recommend aggressive study and utilization of CAM, that adequate funding will be budgeted for study of various therapies and financing will be appropriated for low-income patients so they may obtain these services as well.

Thank you very much.

MAN: Thank you very much. John Huber?

HUBER: I'm Dr. John Huber. I'm a chiropractor. I practiced for twenty years in the Kent area and for the last five years, I've been teaching at a community college. We have an integrated health program in our college. In addition to nursing and dental assisting, respiratory care, and medical assisting, we have a chiropractic technician-training program. We teach our technicians how to take x-rays and help with the exam process. They assist in therapy and help in the coding and documentation process.

One of the big problems we've seen with integration of CAM, and especially chiropractic, into traditional forms of payment, like insurance companies, is the type of documentation they require. So we're kind of driving the protocol backward by teaching paraprofessionals how to support doctors in getting their documentation done properly. It's kind of a backward way. The chiropractic schools really don't have time to go into a lot of detail about coding choices and the kinds of things that payers are looking for. We are trying to fill that gap by supplying chiropractors with very competent, highly skilled paraprofessionals. We would like to see that duplicated across the country. There are only a few programs like this in existence.

Some of the barriers are the startup costs -- it costs $100,000 to $200,000 to start up a program when you consider the x-ray facilities, equipping labs. Curriculum is a big problem also. There aren't a lot of programs around, so developing curriculum is pretty tough. We were able to get a federal grant to help with that, to do a skills-standard study, to give us a task analysis to base our curriculum on. So that was very helpful.

Other barriers include enrollment. While CAM services are popular with the public, from a patient standpoint, getting students interested in going into paraprofessional programs to support CAM is difficult, because it's not well known or not well understood what it is that they do, what kind of training they need. Also we had some attitudes to overcome on campus, as you might imagine. When the nursing program heard that chiropractic was coming to campus, there were some issues -- some petitions and those kinds of things.

But here in Washington State, we have a much more open attitude about alternative ideas. We have really come a long way in the last five years. We also now offer programs for doctors and current paraprofessionals. We try to keep doctors up to speed on all the changes that occur every year with coding and relative values and all of those kinds of things, so that the parts of our services that are covered in insurance we can do appropriately and bill for appropriately. We also teach doctors issues about new outcome tools that are available and how to apply them in their clinical practices. We talk quite a bit about quality-control issues. I just wanted to let you know that that program was there and that we're trying to help the integration process by bringing CAM education to public colleges.

MAN: Thank you very much. We have some time for questions. Would you like to begin, Tom?

Questions from Commissioners

CHAPPELL: Yes, thank you. May I ask Mr. DeShields and Mr. Turner, as consumers of these modalities, are there some things that didn't go well that you'd like to see changed? Are there some principles that you'd like to see us address as we do our work, from the consumer's point of view?

DESHIELDS: I would like to see a way that my health insurance pays for it instead of me paying for it out of my pocket. Had I used the traditional methods, they would have been paid for, but I still wouldn't be cured.

TURNER: I thoroughly agree with that as well. Also, I've been fortunate in being in two studies, one for acupuncture and one for massage, which has been paid for. So that's why I was recommending studies as well, so that people could utilize that as a funding source.

WOMAN: Dr. Bomonti, I appreciated very much what you had to say. Could you provide this panel, perhaps, with one concrete recommendation for how you think we can help prevent the co-optation of the vitalistic movements, from being sort of co-opted by mainstream allopathic medicine?

BOMONTI: I can give you three quick suggestions: One, the utilization of CAM procedures -- and this was in the testimony; it's in written form -- by non-CAM providers after a weekend course or something of this nature be ceased; that the certification by allopathic boards of allopaths of CAM procedures, when they have no training and background, other than through an allopathic model, cease. The other is much more philosophical, if you will, and that is that we each have to recognize that we have strengths and weaknesses, whether we're allopathic or CAM, and that none of us has all the answers. But together we can come together with a way -- not the way, but a way -- that we can improve the health of mankind. I think it's most important also to recognize that it is not something that we do to the patient, it is something we do with the patient. The patient has to also create that responsibility within themselves to make it happen.

WOMAN: Dr. Bomonti, I would like to thank you very much for bringing the issue of vitalism and the body's ability to heal itself to the forefront. I hope we'll have a lot of discussions on that subject across the United States -- and also for mentioning that health is a partnership. The doctor does his or her job, and the patient has their sense of responsibility, too. Thank you.

WOMAN: I also reflect that thanks to you. You mentioned about the alternative. That term "alternative," from your description of the atomistic and the other offensive unit -- do you have other terms that you recommend for saying "alternative"?

BOMONTI: I don't think, in the political environment in this country, that changing the vocabulary right at this moment is possible. If we look at the world -- and I'm sure you're all aware -- allopathic medicine is the alternative, and vitalistic health care is the mainstream. However, if we're going to get anything done at this point, I don't know another way of saying it. I wish I did.

MAN: I have a question for Mr. Turner regarding your experience with acupuncture, massage, and also chiropractic treatment. From your point of view, how many treatments do you think are appropriate per week for acupuncture, plus -- is it at the same time?

TURNER: Acupuncture, I go once a week. Usually each session is beneficial between one and four to five days, depending upon the severity. Massage, I go every four to six weeks. With chiropractic, I've been fortunate to where I only need it after my seizures, for probably anywhere from six to ten times.

MAN: So if you have a choice, like massage therapy and acupuncture and the chiropractor, two or three times per week would be enough?

TURNER: I think that would be beneficial in my case. I think it's on a person-by-person basis, and what they're going through at that particular time.

MAN: Dr. Bomonti, I appreciate your candor and your comments. You have a quote here in your testimony, that you want accountable healing modalities on their terms -- that is, the CAM providers' terms. With that in mind, how do you feel about the licensure movement and the accreditation movement? How can you envision concrete ways to have a licensing/accountability movement that brings in the voice of the CAM provider, and it's not an allopathic model, but it's a sort of synergistic model? Have you thought about ways of doing that without usurping --

BOMONTI: The licensing model is something that -- obviously, each state has its own licensing boards. They are licensed and tested on the basis of their profession, whether it's allopathic or chiropractic or naturopathy or acupuncture, et cetera. I believe that's appropriate, that each profession do that. As far as standards are concerned, what I see today is that we have disease-focused outcomes that do not focus on what is the quality of life of that person, beyond just existing. There is so much potential that I believe the vitalistic professions provide that is beyond just being symptom-free. That's about fifty percent of our potential. The vitalistic professions, in my opinion, can take it beyond that, obviously with the help of the patient or the person, to reach that potential. This is the first time, I think, in history that we have had the luxury to be able to look beyond survival.

As I said, allopathic medicine -- there's nothing wrong with allopathic medicine at this point, except that we are now at a point where we can get beyond just surviving. Now we have the opportunity to enjoy that life that we could have. The vitalistic professions, in my opinion, can assist in that process.

MAN: Effie, you had a question?

CHOW: I don't think you mentioned it in your presentation, but in your written presentation you're saying you're a little pessimistic; you don't think that much will be accomplished, any substantive change.

BOMONTI: Yes. I thought someone might catch that.

CHOW: I'm a little troubled by your pessimism in that statement, where all the rest of your statements are so wonderfully optimistic. I just want to say that it's not us that's going to change. Your statement says, "For us to help make the change." But it really is you folks who are going to help us make the change.

BOMONTI: If you'll notice in the last sentence, we have to rise above our own personal belief systems. You, though, are the people who -- I can read it, if you would like. In closing, with due respect, with sincere appreciation of the apparent intent and personal integrity of the fifteen people who are on this Commission, I must state that, given the past, I do not hold much hope that anything more than a small possibility exists that anything will change as a result of this process we have begun. To make any substantive change will require each of you to become more than who you were when you were appointed to this Commission, as distinguished as that may have been, and to overcome not only the obvious politics of Washington, D.C., but to rise above our own -- our own -- personal belief systems and professional tribal politics to focus on how all of us can become a team for our common purpose. I wish you well and support you in that quest.

You will notice that it shifted from you to us. We all must do the same, but you are in the spotlight. It is a huge task that is asked of you. You must become more than you were.

WOMAN: Thank you. I guess I want to just emphasize again that we can only do what you help us to you -- not only to you, but to everybody who is here and we'll be in contact with.

BOMONTI: That's why we're here.

MAN: It's interesting. I appreciate the reminder. I'm reminded, of course, that the process of individual healing is very much like the process of collective healing, and that we're engaged in that process here.

I wanted to ask you two guys, who are patients in these programs, aside from the techniques, what do you notice about these clinics that you went to that was different? From the patient's side of going to a community clinic, what was there about the experience that said to you, this is a different or a better healing experience than I've had in the conventional clinics to which I've been?

DESHIELDS: I got a sense that they truly cared and that I was not a dollar sign coming through the door. That was evident by the amount of time that they spent. On more than one visit, they spent a lot of time, whereas most of the physicians -- "boom, bam, thank you, ma'am," and you're gone.

TURNER: I'd say mine has been in complement with my Western medicine. There is much more touch involved, which I think is important. But it has definitely been a complement to my Western medications. In my case, I had to find something, in addition to my Western medications, to help me stay on those as well. Most of these -- the acupuncture that I do is done right in my doctor's office. They have a clinic two nights a week where these acupuncturists come in and do it. It's in my doctor's office.

But the sense of touch, I guess, is the main thing.

MAN: Thank you very much. Thank you all.

We'll go on to the next panel now. The first speaker is Lawrence Jacobson.

Speakers

JACOBSON: Good afternoon. I'd like to thank the panel for taking the time and the effort to come here. We know that it's not an easy thing for you to do and that you're all very busy. Again, thank you very much for the time to listen.

I have five years in my own consulting business, and a little bit of a unique point of view, I think, because I've spent a lot of time working both with the providers and with the health plans. I don't think there are very many people who have gone back and forth, as well as being a consumer. So I try to balance all those points of reference. I think it's very easy to just point a finger and trash the health-plan people. It's also very easy to point a finger and trash the providers. I think the real task is to think out of the box. I think that's the point that was made over here. We have to begin to think differently. We have to think in a multidisciplinary manner.

I've also been one of the facilitators of the group that Lori Bielinski talked about earlier, the clinician work group that was initially proposed by Deborah Sen's office, the insurance commissioner. The task that we as facilitators had was how to bring together some very different kinds of disciplines, bring together massage therapy, acupuncture, chiropractic, the various different CAM disciplines, but then also bring together health-plan medical directors of a number of different backgrounds, and then a little of a unique task that I jumped into, to try to bring some primary-care providers onto the group. So it was a very mixed group, a very challenging group to get to speak the same language. We spent three years working on that project.

The every-category law, which has been mentioned a lot, is the impetus for bringing what was previously underground -- the system of providing CAM services that many people didn't acknowledge -- up to the surface and saying, okay, insurance companies have to begin paying for it. But how do you do that? I'm not saying we have the answers, but I think, through our three-year process, we raised a lot of really important questions. Many of them you've already heard today and I won't spend a lot of time repeating.

I think the key issue from that process that I got was the importance of process, bringing those people together on a regular basis, multidisciplinary kinds of people. I'll skip now to my recommendations.

First of all, I think we have to solicit opportunities for integration in conventional medicine. We have to look for where within the conventional system we can begin talking about these different disciplines and including them and studying them. We need access to up-to-date, reliable CAM information for consumers. Consumers are very, very confused about this. They don't know, as David Eisenberg points out in his studies, whether to talk about their conventional services with their CAM providers and vice versa. They need better access to information. I'd like to applaud the many providers who have done excellent work in this area, but there is a lot more work to do.

We need resources for multidisciplinary research and opportunities for communication with conventional medical providers. We have the technology now with the Internet to reach many, many people, but we have to figure out what information is good and how to get that information out there. It has been suggested here that a national multidisciplinary process that includes payer groups, purchaser groups, and consumer groups could be very effective. I think the model we created for the CWIC was a strong one.

We need to move away from a multi-tiered system, where the Medicare/Medicaid people and people who don't have insurance are separate. We need to bring people together who have commercial insurance, people who have private insurance, and find a way of managing the benefits to make it available to all folks, so that these disciplines can be defined. What's quality? What's not quality? Let's work together on it. I think that's the point of our work group.

Thank you for your time.

MAN: Thank you. Laura Patton?

PATTON: Good afternoon. I'm the clinical director of alternative services at Group Health Cooperative. Group Health is a consumer-governed HMO that was founded in 1947 and provides prepaid comprehensive, coordinated care to approximately 590,000 enrollees in the state of Washington. We are the largest consumer-governed health-care system in the nation.

Since 1996, most of our consumers have had access to a program of covered CAM services, which is trying to do what Commissioner Chow alluded to earlier today when she spoke about paying only for services that are effective, and not for anything else, even though it does get into trouble. I don't have time to tell you the specifics of our program, but I will briefly discuss three assertions and make several recommendations.

My first assertion is that consumers value CAM services and are looking to their conventional medical providers to guide them. That they value CAM services is pretty obvious. It's the primary reason we're all in the room together today. But they are being bombarded with information that is often confusing, inaccurate, or incomplete. They want their conventional providers to be able to give them objective, reliable information. These providers need help in order to fulfill these expectations.

My second assertion is that health-care systems and mainstream medical training facilities need to take primary responsibility for initiating the dialogue with CAM professions. In this area, we have been lucky because that collaboration has been quite a bit easier than, perhaps, in other areas. It's my belief that taking the initiative will become easier, particularly for health plans considering CAM coverage, once our experience in Washington has been thoroughly analyzed and broadly disseminated. Assertion number three is that collaboration precedes integration. I wrote that because, until today, I had heard very little about the process of how to get to integration. We talk mostly about how important integrated medicine is, but not so much about how to get there. True integration requires major behavioral changes on the part of both CAM and conventional providers. This degree of change does not occur quickly and will require collaboration at multiple levels, most of which have been talked about today. But the most basic level for me as a practicing physician is the level of the communication between the patient and the conventional provider about CAM. We've worked very hard at Group Health to make that conversation a little bit easier.

I'm going to move to my recommendations: Number one, establish a clearinghouse for all CAM-related articles published in peer-reviewed scientific journals which would be easily accessible to all medical professionals -- for example, an Internet site with monthly updates.

Number two, work with the FDA or other appropriate agencies to develop mandatory manufacturing standards for producers of herbal products, which are, after all, medicines. Support efforts of CAM professions in guideline development. I think that's very important. Encourage conventional medical schools to require at least one course about CAM, including observation of CAM practices and personal experience. Finally, involve consumers, including skeptics -- the people who are not here in this room ?? in all levels of information gathering and decision making.

Thank you for this opportunity to speak.

MAN: Thank you. Elizabeth Goldblatt.

GOLDBLATT: I'm Liza Goldblatt, president of the Oregon College of Oriental Medicine, Portland, Oregon, and also of the Council of Colleges of Acupuncture and Oriental Medicine, which represents over forty accredited colleges that are located throughout the U.S. There are about 12,000 licensed acupuncturists and about 7000 students. Forty-one states, plus D.C., do regulate the medicine. We're under the purview of the Accreditation Commission for Acupuncture and Oriental Medicine, which is recognized by both the U.S. Department of Education and CHIA (phonetic). We currently offer a master's program and have just developed the final guidelines for the doctoral program.

I was asked to address issues of strengthening professional accountability in our field. At this point, the educational standards for comprehensively trained TCM providers are recognized. There are many health-care providers that are practicing parts of TCM medicine at different levels -- for example, acupuncture. We really need to discuss the educational standards with defined competencies for these health-care providers.

Another issue has to do with titles for practitioners and scopes of practice. These should be reflected in their educational training. For example, the LAC is trained as a primary acupuncture and oriental medicine provider. Most states do not yet have articulated levels of CAM training for MDs. There are over eight hundred public-health clinics in the U.S. that use acupuncture and Oriental medicine for the treatment of chemical dependency. Some of these utilize what is called the ADS, acupuncture detox specialist, which is another level of training.

We're currently working at the federal level on the loan-forgiveness program, including acupuncture and Oriental medicine, and it's stuck in committee. If this Commission can help us move it out of committee, we would be most grateful.

We recommend that all medical colleges, CAM and allopathic alike, begin to require survey courses on the other medical fields, to know when to recommend and refer to other health-care providers. Collaborative internships should be strongly encouraged, as well as working in integrated clinics. To be quite candid, most of the integrated clinics I hear about throughout the United States are really practitioners under the same roof. A very few are working in what we would consider to be truly integrated models.

Recommendations are to include CAM practitioners in the loan-forgiveness program, to begin to fund think-tanks that would bring together the educators to address the appropriate curriculums to establish in medical colleges, as well as establishing how to work in collaborative internship programs; also funding for truly collaborative medical clinics throughout the United States that could have research branches on the best practices, as well as educational branches that would focus on internships.

I think it's fairly clear to all of us, particularly when we look at the ontological perspective of health care in the U.S., that the future of medicine ideally will focus on health, wellness, and the treatment of chronic diseases. Some of the CAM practices have long histories in focusing on these areas. It's time, really, for the health-care providers to not only be healers, but truly become educators.

Thank you.

MAN: Thank you. JoAnne Myers-Ciecko.

MYERS-CIECKO: I'm the executive director of the Seattle Midwifery School. It's a private, nonprofit, community-based organization that trains midwives, birth and postpartum doulas, and childbirth educators. I'm not a midwife myself, but came to my work through my own personal experience with midwifery care in a home birth twenty-five years ago.

Direct-entry midwives are experts in normal birth and provide care to childbearing women that emphasizes partnership, informed choice, holistic care, and a wellness orientation. There are over five hundred direct-entry midwives in the United States today who are certified by the North American Registry of Midwives. There are over seven hundred direct-entry midwives licensed or otherwise regulated in seventeen states. All of these states now use the written examination administered by NARM as a required element in the state licensing process. Altogether, these midwives represent fifteen percent or more of all midwives nationwide.

Direct-entry midwives enter the profession through multiple routes, including freestanding accredited schools, programs within accredited institutions, and apprenticeship. Regardless of the path any student might follow to become a certified professional midwife, she must demonstrate competency in each of the core competencies described by the Midwives Alliance of North America and the minimum experiential requirements established by NARM. The Midwifery Education Accreditation Council currently accredits or pre-accredits eight programs in six states and has five additional programs in the pipeline. MEAC submitted their petition for recognition by the U.S. Department of Education as an accrediting agency in November of 1999 and a decision is expected in December of this year.

Most direct-entry midwives are self-employed, providing community-based services and attending births in their clients' homes or in freestanding birth centers. Many direct-entry midwives also do related work in fields such as community and public health, family planning, and health education. This year a local Seattle hospital has initiated a pilot project granting hospital privileges to licensed midwives, who can now offer clients a choice of home, birth center, or hospital delivery. Also this year, the National Safe Motherhood Award went to a midwifery program at Allevial (phonetic) Medical Center, a federally qualified community health center serving the south side of Chicago. This midwifery program employs direct-entry midwives, nurse midwives, and OBs. They do over one thousand births per year, twenty percent of them at home.

I would draw your attention to the recommendations of Pugh Health Professions Commission Task Force on Midwifery. These fourteen recommendations are organized by five issue areas: practice, regulation and credentialing, education, research, and policy.

MAN: Thank you very much. Let's begin the questions with Joe.

Questions from Commissioners

FINS: Dr. Patton, regarding the Puget Sound cooperative, could you sort of break down the number of dollars that are spent in your annual budget on CAM therapies, and what percentage of the capitation fee at the outset is earmarked for those services?

PATTON: I'll be happy to send you the information. I'm not sure it will be totally accurate off the top of my head. We have a couple of different funding mechanisms for our CAM program. For chiropractic, which is a pretty longstanding program -- it has existed since about 1992 -- we have a very stable network of chiropractors who are capitated. We spend approximately $4.5 million a year on chiropractic services. In the other three areas of CAM, which are massage therapy, acupuncture, and naturopathy, we have a discount fee-for-service reimbursement arrangement with a contracted network of providers. On those services, just on direct claims costs, we spend probably about $1.5 million a year.

FINS: When you send us this information, can we get several years, so we can see trends, if possible?

PATTON: You want to see trends?

FINS: That would be helpful.

PATTON: Yes, all right.

MAN: And also, with that, a little bit of history of how the program evolved. I think that would be helpful, too, because your own history as a program overall lends real importance to whatever you can tell us about you've evolved.

MAN: I have a question for Dr. Goldblatt. I understand that American acupuncture schools and colleges have been improving a lot . . . the program twenty-seven hundred hours, including five hundred hours practicing, for three-year study?

GOLDBLATT: Actually, the Accreditation Commission has two different levels of training. One is a master's in acupuncture, and the other is a master's in Oriental medicine. I would say that the average training programs are anywhere between twenty-five hundred and three thousand hours, not including the prerequisites, which are a minimum of two years of education. Most of the clinical programs at this point probably vary anywhere between seven hundred and a thousand hours. So there is still a good deal of variation in those areas. The doctoral program that we have just completed the guidelines for is a minimum of four thousand hours, which will include the master's program.

So while the Accreditation Commission has not actually looked at the number of hours, really, for several years -- mostly because it's more vocational programs that tend to look at hours and it's been more focusing on the quality elements -- my own sense is that, having been on about sixteen accreditation visits at this point, the quality of the programs has indeed moved to what we would certainly consider to be a master's-degree level.

MAN: By the way, the insurance also covers non-physician practitioners who practice acupuncture in most states?

GOLDBLATT: There are several insurance policies that currently do cover acupuncture and Oriental medicine, but I would need to defer that to some other people here with that expertise, such as Barbara Mitchell, who I know is here today. You'll hear from her later on. But there are a number of programs today that do.

MAN: You mentioned acupuncture. Also you mentioned Oriental medicine. Can you tell us the definition? You don't have to tell us about acupuncture. We all know acupuncture.

GOLDBLATT: Well, it is an interesting semantic issue, that's true. Generally, when we use the term "Oriental medicine," we're basically referring, most of the time, in terms of our colleges, to traditional Chinese medicine. However, we often use the term "Oriental medicine" to encompass the other traditions that exist, such as those from Japan, from Korea, from Vietnam, and from Europe. But the vast majority of the colleges are offering programs in what we would define as traditional Chinese medical colleges. There are indeed often training programs in some of the colleges on Japanese acupuncture, some on the European tradition, which is referred to as the Worsley tradition.

So we tend to interchange TCM and Oriental medicine.

WOMAN: I have a question for Mr. Jacobson. In your discussion about bringing together CAM practitioners and care providers, you mentioned speaking the same language. Do you mean speaking the same language or understanding one of the -- do you think we have to speak the same language?

JACOBSON: I didn't mean that literally. But I'll tell you, when we brought the work group together, the first six months was just putting multidisciplinary folks together so that they would begin to understand the reference points of each other. One would normally think, in this country, there's so much interaction -- in this community, particularly -- between different kinds of disciplines and different kinds of backgrounds. But we found, without doing that, we would have had to keep going backward. Because we took the first six months to better understand each other and meet together in multidisciplinary groups -- and some of it was just very simple, like seating arrangements, where you would have a health-plan medical director sitting next to an acupuncturist, sitting next to a midwife, sitting next to a naturopathic physician. It seems very simple, but yet it doesn't happen. So by creating that kind of atmosphere, we were able to create a lot of change and a lot of relationship building.

WOMAN: So you're speaking about being able to understand what each person is saying, not necessarily developing the same language.

JACOBSON: Correct.

WOMAN: I'd like to address my concerns to Dr. Patton. Perhaps you can come up with some suggestions and solutions, both in the categories of education and appropriateness of care. Our office has been primary-care providers with Group Health since the beginning. We found out, because there's an administrator, out of state -- back in New Jersey, as a matter of fact -- who's unfamiliar with our state law and unfamiliar with the chiropractic guidelines and clinical practice, unfamiliar with the research that's been done to support the correction of the vertebral subluxation, we've just been stymied, really, in our efforts to deliver what we feel is appropriate care. Just this year, as of December 31st, we have terminated our relationship with Group Health. I feel badly about that. There's a barrier to education. I'd like to know how you think we could overcome that.

PATTON: It's hard to know how to answer that. I think what you may be referring to is part of our utilization management and quality-assurance program with respect to chiropractic. These are two functions that we delegate to a network management company, American Whole Health Networks. They have a board of chiropractors that renders determinations to decide whether more care is medically appropriate or not. This actually, I feel, is a good model for the other CAM professionals, to have the professions themselves make those determinations. In that respect, I think it's a good thing.

I don't know how to particularly address the needs -- I know the individual about whom you're talking. I don't know the extent to which regional differences play a part in how he, as the head of that chiropractic board, makes the determinations. But that could be a conversation that we could have at some depth later.

WOMAN: JoAnne, we heard earlier from a woman who talked about her experience with a home birth and then being transported, and sort of the less-than-receptive response that she had. As somebody who has attended many home births and had my babies at home, this state seems very open and progressive compared to many states, where midwifery really isn't well tolerated, or even legal. If you had one message to give this Commission, what you would like us to really know -- if you could have one, on behalf of midwives, because we haven't had many midwives come and speak -- could you give us something?

MYERS-CIECKO: Well, I think we have a maternity-care system that's upside-down in this country and relies too much on specialist care and not enough on orientation to wellness, prevention, care that midwives provide. There are a lot of historical factors, obviously, that go into that -- I call them technical difficulties, basically -- that need to be addressed. But I think underlying that is sort of a deeply rooted prejudice against midwifery in this country that's social and professional, both. So long as allopathic physicians are trained and oriented and driven to assume the full responsibility for the provision of care, for the health of the women they serve, and bear that awful, heavy responsibility that they feel as a result of that training, those expectations, rather than the partnership model that we've all been talking about here today, it's going to be really hard to overcome those biases and those technical difficulties. They just keep getting in the way.

WOMAN: Do residents follow lay midwives, licensed midwives, to do home births, residents in Ob/Gyn and family practice, to really get a flavor for that?

MYERS-CIECKO: They haven't yet. There has been some discussion, but nothing that has really borne fruit yet. An excellent idea, though.

MAN: Dr. Patton, I want to be sure I paraphrase what I understood you to say about the preferences of the 590,000 members that they would like their primary-care physicians to provide the answers to their questions about CAM services and products. I just want to check out whether I heard that correctly.

PATTON: I think you're hearing me say that, as well as, implied but not stated, that when we started our program at Group Health, I think the most common comment I heard from our Group Health providers was, "How can I possibly guide these people? I don't know anything about any of this." It's both of those things.

MAN: Good. But I guess I wanted to check with Mr. Jacobson to just see if in your business experience -- you made the statement that consumers need access to more up-to-date, accurate information -- would you agree that consumers indeed defer to a primary-care physician for the answers?

JACOBSON: I'm not sure you can generalize it. There are so many different kinds of consumers. But I think, as a society, we've said to consumers more and more, and I think we'll continue to say, "It's your responsibility, so you'd better try to figure out more about this." We need to provide them more accurate information and a means to educate themselves, because, more and more, they're going to be the ones making the decision rather than the purchasers or the health plans or even the primary-care providers. I think we're sort of stuck in limbo there. We haven't quite decided how far we're going to go. But I think that's where we're headed.

MAN: Ms. Myers-Ciecko, I just wanted to ask you about the allopathic approach to infertility, and whether or not midwifery has anything to say about that.

MYERS-CIECKO: You're outside of my realm. I'm not the clinician, and it's not a place where I've . . .

The Honorable James Gordon: Okay, we'll begin with Susan Haeger. Hi.

Susan Haeger, Citizens for Health (National): Thank you Dr. Gordon. Hello. So I thought first I would just say who is Citizens for Health and why are we here. We are the nation's largest grassroots consumer advocacy group promoting consumer access information and choice for natural health care. I think we've been the strongest voice at both state and federal levels for consumer access, in defense of consumer choice with respect to health care and wellness. And in the past seven years Citizens for Health has worked to generate consumer response to federal agencies and to Congress when there have been either legislative or regulatory challenges that affect that choice, information and access. We've generated millions of letters into these agencies and into the federal government and we really represent a population of people who are taking their health care into their own hands. I think this is the population that has driven the creation of this commission. And my thought on this is to paraphrase Gandhi that where the people lead the leaders must follow.

And I think that's what's happening here. The public seems to be ahead of most practitioners and policy makers seeking innovative health promoting care. It's, we're seeing the development of this emerging model where the population intuits their need for preventative care is receiving conflicting messages about how they should approach it. And that's why we're very grateful to see the establishment of this commission to hopefully give clear guidance.

I believe that for the commission's recommendations to become law and to be implemented into the society we need to mobilize the support of these millions of consumers. Dr. Gordon and I actually spoke about that the other day. And there's three basic principles I think need to drive the commission's work in order for this population of consumers to really get behind its work.

One is access of choice, really insuring choice, freedom of information, and also ensuring protection from unscrupulous providers. Under choice, I think this includes particularly the driving force for most consumers is seeing inclusion in insurance. Access to different kinds of providers. Not just having conventional medical doctors now trained in certain canned professions, but truly having access to a wide variety of providers. Having access to products, whether it's dietary supplements or health aids and the ability for them to act on those things they believe can most help them. This is reflected in the fact that this is where people are spending most of their out of pocket health care dollars. They're deciding what they think will help them most. They're paying for it themselves out of their pocket, the tune of billions of dollars. And it's critical that government remove artificial barriers to consumer choice. I think state governments, in particular, have to be educated on the benefits of CAM practices because health care truly can't be integrated unless we have credentialed, licensed practitioners who can work along side conventional medical doctors. Washington State has certainly led in this endeavor.

Freedom of information is critical allowing physicians and practitioners to give all range of options to their patients. Many, many circumstances in America today, we find consumers deciding what they think is best for them. We find either their physician by law cannot give it to them. Or that state agencies will take their children if they try to provide it. These kind of barriers need to be removed.

We need to remove sanctions around orthodoxy. One of our efforts that we've worked on quite a bit has been dental boards. We find dental boards had an ethical rule that a dentist could not speak to their patient about mercury in fillings. These are the kind of barriers that create consumers being very upset about their inability to get their CAM provided.

Am I out of time, Jim? Just say really quickly in terms of production from unscrupulous individuals, groups and companies. I think it's, we have to be honest and say that there are unscrupulous individuals who will prey upon people who have diseases, life threatening illnesses. And we've got to create accountability in regulatory agencies. And states have to decide that it's important to regulate CAM professions. So I look forward to presenting more comments in writing. And I apologize, I thought I had five minutes.

The Honorable James Gordon: Thank you very much. Michelle Simon.

Michelle Simon: My name is Michelle Simon. I'm a third year student at Bastyr University in the Naturopathic Medicine Program. I'm here to address issues concerning the health needs of underserved and rural communities which might best be served by integrated health care clinics. There's a great deal of interest among my classmates to meet this challenge, to work in underserved and rural areas and to help educate communities in good health practices. We are a ready, willing and able workforce. Naturopathic medicine is, in my opinion, an extremely well suited modality to serve these populations. Alternative medicine in general, and naturopathic medicine in particular, holds as a basic tenet the importance of preventative measures rather than the costly intern solutions. This economic benefit addresses one of the issues which limits the care communities in need receive as the current state of the medical care necessitates a high cost of delivery. By educating patients with regard to lifestyle choices and their consequences and indeed seek to avoid the costly interventions which may be necessary in later stages of disease. If necessary NDs refer and co-manage cases with other providers of health care. This type of cross referral is simplified if the practice is in an integrated clinic.

There are several clinics in our area that currently practice an integrated model of care. Providers included in this model of care are MDs, NDs, LPNs, DOs, PTs, massage therapists, chiropractors, and acupuncturists. At one integrated clinic, The Healing Art Center in Colville, Washington, strong patient demand has resulted in greater than expected growth of their patient base. Patients are aware of the possibilities. In the 1995 survey of Community Health Center of King County patients indicated that sixty percent of current patients were interested in receiving natural medicine services. Some strengths of integrated clinics are the rich synergy of treatment options available for patients--a high patient satisfaction that focuses on benefited integrated approach to care in Caseco Management, which provides overall prospective and decreased risk for patient health.

My suggestions in specific, are to provide grants to community, rural and underserved clinics for the express purpose of brining aboard licensed CAM practitioners to work in an integrated capacity. Secondly, to include reimbursement for licensed CAM services among federally managed health care plans, such as Medicare and Medicaid. And third, to fund naturopathic medication, sorry, education in the form of scholarships, loans and national loan reimbursement programs for licensed disciplines. Thank you.

The Honorable James Gordon: Thank you. Julie Chinnock.

Julie Chinnock: Good afternoon. My name is Julie Chinnock and I'm currently a third year student in the Naturopathic Medicine program at Bastyr University. I want to thank you for coming to Seattle and also to provide us with this opportunity to provide you with our prospective and this information. The reason why I'm here is to tell you that once I graduate as a fully trained naturopathic primary care physician it is my goal to practice in a health care shortage area. In this regard I am also speaking for up to sixty percent of my classmates.

Currently this option is not even minutely financially feasible to us in any other state but Washington state. Under the Washington State Health Professional Loan Repayment and Scholarship Program primary care health professionals including naturopathic physicians, licensed midwives and pharmacists doctors are not only eligible but encouraged to work in those areas where there are health care service gaps. But even then there are limitations here when it comes to funding CAM providers. Speaking solely of Washington state, there are community, public and private clinics that have expressed interest in hosting CAM providers with this program. Yet they lack federal CAM health care reimbursement such as Medicare and Medicaid making it impossible for them to fund a salary for a CAM provider. With the funding and reimbursement as it currently is there is little chance that we can practically serve in underserved areas without working for free and or the risk of default on our student loans.

So how is it possible for willing CAM providers to effectively work in those areas which need health care the most? First, funding. Through federal funding in all states rural and underserved clinics should have the option for integration with licensed CAM providers including acupuncturists, naturopathic physicians and midwives. This includes grants and scholarships, subsidies for salaries, student loan reimbursement programs and patient CAM health care coverage through existing federal and state health coverage programs.

Second, legislation. Changes should be made in federal legislation to include licensed CAM providers in all programs that currently cover and fund other primary care providers. Third, outreach and integration. Once rural and underserved clinics are eligible and able to participate in these loan reimbursement programs, widespread outreach is necessary to inform them of current successful integrative clinics, some of which were mentioned, and dissemination of valid information on CAM providers to stanch the myths which may be out there which currently discriminate against our abilities and professions.

There is a current and emerging qualified workforce of CAM providers who are in demand and lined up to work in those parts of our country that are lacking in health care coverage the most. With assistance from the federal government, assistance that is already granted to a portion of primary care physicians, we will be able to afford to provide this care, pay back our educational debt and Americans from all income levels will better receive the health care that they want and they need.

The Honorable James Gordon: Thank you. Chris LePisto please.

Chris LePisto: My name is Christopher LePisto and I'm a student of Naturopathic Medicine at Bastyr University. The question posed is how can access to safe and effective CAM practices and interventions be improved? An answer is the inclusion of naturopathic doctors in the National Health Service Corps, the NHSC. The NHSC's primary goal is to deliver and retain in underserved communities clinicians that can help meet their health care needs. It currently does not include naturopathic doctors. You might be asking yourself why should we include them on top of the many fine professions already in the NHSC.

First, naturopathic doctors are fully trained and licensed CAM practitioners who can provide for safe and effective access to CAM health needs. Institutions like Bastyr University here in Seattle are now leading academic centers for advancing knowledge in the natural health sciences with world renowned faculty and researchers producing excellent CAM providers.

Second, it is estimated that perhaps sixty percent of naturopathic students are interested in practice within an underserved community. Sixty percent. This is a huge resource that is to date effectively excluded from the NHSC. Lastly, students like myself will be graduating with a loan debt with approximately a hundred thousand dollars. As graduates it is critical we have access to the federal loan repayment programs and the community scholarships contained within the NHSC. Now this access must come through legislation. Renewal legislation of the NHSC is likely to take place in the very near future. This happens once every ten years. If legislation were to include language supporting the inclusion of naturopathic doctors as another NHSC primary care provider. These doctors could care for the medically underserved while participating in the NHSC's programs. Access to safe and effective CAM practitioners could be significantly improved.

Here are the action steps that I am recommending. First, make a strong recommendation that naturopathic doctors be included in the language for renewal of NHSC legislation, encourage inclusive language concerning all the established CAM professions. Second, support licensure for naturopathic doctors in all fifty states. Lastly, listen to the recommendations of the Capital Area Rural Health Roundtable, a coalition of health professionals which has monthly meetings regarding the reauthorization of the NHSC. The inclusion of naturopathic doctors in the NHSC is critical for underserved communities to have access to safe and effective CAM practices. The solution is legislation and that solution is close at hand. I ask you to support the inclusion of one of CAM's great resources. Naturopathic doctors.

The Honorable James Gordon: Thank you. I want to thank all or thank the three of you students of Bastyr for coming and being with us. It was very important to us to hear from students. And thank you other students from Bastyr. I know that you're in the middle of exams now. And actually I'm sure this is a pause that refresh us. So, it's great to have you here. I also think it's very appropriate that that you're on, sitting on the panel with Susan Haeger cause I hear the same kind of fervor. And one of the things I want to emphasize to everyone in the audience is this is truly a popular movement. And it's a movement of people who are looking for care, people are wanting to give care in new ways, people who are coming together to figure out altogether really truly new ways of helping each other out. I'm also extremely happy to hear that sixty percent of your class is interested in serving the underserved. I think that's, that's fabulous. Tom.

The Honorable Tom Chappell: Yes. Susan Haeger, my question is: Are you recommending that freedom of choice from the consumer's point of view mean that they have direct access at their will to any of the practitioners as opposed to going through a primary care physician?

Susan Haeger: Yes.

Tom: Thank you.

Susan Haeger: Although what I, I would like to just amend that by saying I think one of the biggest problems right now in the marketplace is that there are not in relation to specific chronic diseases, other critical care kind of situations, primary care providers that really understand the scope of many other CAM professions. And so, yes I think we are advocating people have direct access and at the same time they have to have direct access in an environment in which it's clear what they're getting access to. And that's why we have to have licensed credentialed practitioners.

Tom: Thank you.

Female Participant: Just a quick comment to the students. You know coming from the state of New Mexico where, where you're not licensed yet, we are hoping that you all will become licensed. New Mexico's, the University of Mew Mexico there, our program is really directed at rural care. Underserved, we still have seven counties, entire counties that have not even an ambulance driver. I mean so we have no health care, so we need all the hearts and hands that are out there. And so, you know, I do appreciate you coming here and I sure hope that we get you on, on board on those fifty states and on the National Health Services Corps.

Female Participant: I have a question for Chris. Excuse me. It's kind of two part. I'd like to know if there is one national definition for naturopathic practice or if they differ within the states. And then the second part is that, that is what is the argument against licensure in the states that don't do it at present?

Chris LePisto: So earlier it was brought up the distinction between those students that are at colleges that aren't accredited. In other words, some are graduating with four year degrees and others that have mail order degrees. Those are the same titles nationally--naturopathic doctors. So I'll speak for our profession of four year trained students. There's, there's a coalition called the American Association for Naturopathic Physicians that has a definition for naturopaths and that's the one that we ascribe to here in the state of Washington. And the, refresh me your second question.

Female Participant: I was wondering what the barriers were and you explained that basically, the credentialing question and the training question.

Chris LePisto: Right, yes. So I, I'm posing licensure in all fifty states. So currently naturopaths are licensed in thirteen states. And it very much depends on a state to state basis the opposition there. Some of that comes from mail order schools. I'll tell you, for example, in the state of Colorado where I'm from the opposition has hired the most expensive lobbyist in Denver because they can afford it and those happened to be from schools that that have mail order degrees. So that's the case for Colorado. It's entirely depending on the states and each state is fighting their own battle.

Female Participant: I also commend the students because going into a profession and with all that time and money and coming out and not really knowing where you're going to get your dollars and make your living is very commendable right now. And I guess we need the students to help us make more explicit the requirements to help you people. With that you've begun to give us some outlines that appreciate more detail, not right now, but certainly send it in to us. And Susan Haeger, I want to pursue that freedom of choice. I think that's a very important issue. Are you pursuing legislative action on that too or what?

Susan Haeger: Yes we are. As a matter of fact we've had several pieces of legislation in the federal Congress. We've also helped pass medical freedom legislation in eleven states. And I have to say that in those eleven states today those have been revisions in the Medical Practice Act governing medical doctors, MDs simply because medical doctors themselves were being blocked from practicing CAM therapies by the medical boards who were determining that they shouldn't be able to practice though, that they were fraud. We are also pursuing legally that the federal government would mandate the ERISA program the Employment Security Act, the Employment Retirement Security Act. If that covered CAM professions that would give a a big boost to getting licensure in all fifty states to CAM professionals. And it would also give an indication to the states that they need to take this seriously and begin to enact coverage at the state level.

Female Participant: And there is a legislative number.

Susan Haeger: Well we have others. The Access to Medical Treatment Act, which has been in the House and the Senate and that is again this year not going to pass. It will be probably reintroduced in a new form next year. There is also a Bill HR 3677 in the House called the Thomas DeVarro Patient's Rights Act. That's a specific piece of legislation to allow people to take part in FDA clinical trials as long as they're fully informed through written consent. At this time there are many families who want to get in these trials but the FDA has made the decision that the family shouldn't be in the trial. And these are the type of freedom of choice issues we think need to be pursued.

Female Participant: I think we need some more information from you.

Susan Haeger: Yes and we look forward to providing that to the commission and we will be doing that.

Female Participant: Thank you.

Female Participant: This is directed to the students. I want to commend you. I have a lot or respect for the personal decisions you've made. One brief question is, is, have you ever considered or have you done this, is actually spoken or worked with residents of medical residency programs who have made the choice to do National Health Service Corps and what that life has been like for them?

Chris LePisto: So I don't have any experience with other medical school. I get the hint that you, that it maybe a grueling life of sorts. I would say that any sort of, any sort of loan repayment program certainly has its considerations that go with that. That's a good suggestion.

Female Participant: Yeah, I'm just suggesting that if you're in the same cohort group in age structure it would be a way to actually build some bridges too.

Michelle Simon: There's a group of students at the University of Washington who have formed a program called the Sparks Program and it's actually a club of sorts that meets. And it's people who are interested in, in working in rural and underserved areas including the National Health Service Corps. And we currently have a dialogue with them. And we just had a meeting with them last week actually where they came out to our school and spoke to us about our interest in that and how we could collaborate with them and sort of joining them in their informative sessions and field trips that they take that sort of, that gives students who are interested in these type of programs more information about those.

Male Participant: I just want to commend the students as well. And it's good to see a graduate school that promotes idealism and doesn't destroy it. I want to ask Ms. Haeger a question about your three categories because there's a, there is a little bit of a contradiction there. You're promoting choice but you're also saying we want to protect patients and, and families from, from bad choices. So what are the limits of choice and how do we negotiate that, those shoals, those treacherous shoals? Because we're going to probably make recommendations that will satisfy number three but annoy those proponents of number one in your, in your three levels of issues. How do we handle that?

Susan Haeger: I think, yeah. We had, we had been proponents of the more fully informed a consumer is the better choice they can make that ensures their safety. One of the problems we have in the market today is people have a lot of contradictory information and not much good guidelines. So, for instance, good government regulation, clear guidelines about what constitutes the different CAM professions, how they're regulated, having credentialing, having continuing education, having information in the marketplace about what that criteria is and so a consumer can make a good decision. I bring up the case of this little eight year old girl in North Carolina who died as a result of going to an individual who put himself forward as a naturopathic physician. He was in fact had a mail order MD license from LaSalle University. He had actually been disciplined in another state ten years earlier. He convinced the mother to take the child off of insulin. The child died. This is someone who is acting completely outside of the scope of his training and experience and yet the mother didn't understand that there were no laws within the state of North Carolina.

Male Participant: So would you endorse a provision of having CAM practitioners in the national practitioner databank along with allopathic physicians?

Susan Haeger: Yes.

Male Participant: You would?

Susan Haeger: Yes. I think that the more we can integrate the CAM professions into the system, which has been working, the better. And the challenge is to be able to work within those systems without having the CAM professions completely robbed of what's made them effective for consumers. A good example is state medical boards. The Federation of State Medical Boards is still having individuals at their national conferences speaking from the Quackbusters organization and talking about how the CAM profession is a total quackery. I mean, this is an organization that is giving leadership to all the state medical boards. This is unacceptable when you see the number of consumers that are using these therapies and these modalities. We need to have more integration of good information in the marketplace.

Male Participant: So it's responsible inclusion not exclusion.

Susan Haeger: Correct.

Male Participant: Thank you.

The Honorable James Gordon: Thank you all for [applause]. The next panel: Don Taylor.

Don Taylor: I would ask that you include a modest new requirement with each new research project that is supported; that there be a brief standardized form to be prepared at the conclusion of each trial that describes the number of subjects that were involved, any controls that were used, how the response observed compares to doing nothing to a placebo and to the most effective treatment that we commonly use. In addition, a description of any side effects that were seen should be included. Asking that these results be collected and published and made widely available to patients so that all of the patients can see what kinds of things we're dealing with here.

We are faced with world limited resources here. We don't have the time or the money to try treatment, after treatment, after treatment hoping something is going to work. There's pain, and there is suffering, and there is progression of disease. Patients and even practitioners are not really well equipped to evaluate the efficacy and benefits, and the potential side effects, and even the harm of even a handful of different kinds of treatments.

There is a social cost associated with treatment and we want to minimize that cost. Thus we need easily available and understandable evaluations of the efficacy, and the side effects, and the uncertainty associated with these treatments. This is not available today and you can help make that available to everyone.

One important point does need to be said. Careful measurement of the level of placebo effective with treatment is essential information and should be included in the published results of, particularly in trials like these. With dedication and some creativity it's almost always possible to get an estimate of how large the placebo effect is out there.

During study after study when initial results have indicated that a treatment is unlikely to be efficacious, is using resources that are probably better spent some where else. When more tests of the treatment are unlikely to change the outcome we should stop the testing and apply the results. Conventional medicine and alternative medicine are both guilty of not doing that in some cases.

I'm the first one to say that one example will prove nothing. A friend of mine was in his eighties when cataracts began to take his vision. He lived alone far from any services or care and driving was the last freedom that he had. He was desperately afraid of surgery so he went door to door paying again, and again, and again for a cure. One sold him a trampoline because zero gravity would cure his cataracts. The next put him on a diet and he drove back home and within days he was desperately ill. But he tried to follow her advice and he tried to stay on the diet. By the time that he figured out that he was in real trouble he drove forty miles to the nearest medical care and they discovered that he had had colon cancer for years; the colon was nearly completely blocked. But that the diet he had lived on for eighty years had been sufficient to be able to cope with this and have a good quality of life. The new diet caused constipation, blocked the colon, the colon died. I spent the last month with him in the hospital as he died. Her diet did not cause that cancer but her diet killed him.

How can a patient today decide whether or not a trampoline or a specific diet can cure cataracts? We need to measure the efficacy of these treatments, particularly those who've not had careful evaluations. If we don't expose ineffective treatments others are going to use that against CAM. Thank you.

The Honorable James Gordon: Thank you very much. Cindy Breed, nice to see you.

Cindy Breed, ND, Community Health Centers of King County: Good to see you Jim. Hello and thank you for being here. I'm a naturopathic doctor practicing in the integrated setting of the King County Natural Medicine Clinic at the Kent Community Health Center. In this setting I, along with the other CAM disciplines of acupuncture and massage, practice side by side with conventional medicine providers providing health care services to the medically underserved. Earlier in the day you heard from Tom Trompeter and Judy Featherstone and few others about this same clinic. This integrated care setting gives us the opportunity to improve the quality of care that we can offer to the patients that we serve and the chance to broaden our knowledge of medicine by learning from each other.

Our clinic works because we were able to incorporate CAM providers into an already existing community health center. Initially this idea brought many challenges including acceptance by the existing conventional medicine providers as well as how were we going to make the services available to the people that we serve. Because we have licensing laws here in Washington State for CAM providers we were able to address concerns about standards of training and scope of practice. Through daily contact and cooperation as well as regular meetings we continue to build grow in knowledge and trust among the providers making natural medicine services available to our managed care patients, having a sliding fee scale offered to those without insurance are things that make these services accessible. For our patients with Medicare and fee for service Medicaid, which does not cover natural medicine services we offer the sliding fee scale. This lack of coverage though does limit access for some. Lastly, providing natural medicines like herbs and nutritional supplements to patients on a sliding fee basis is another important piece to providing access.

In order to further expand integrated care-sitting, integrated care settings I believe attention should be focused on these areas. First, nondiscrimination in all government health programs for CAM provider participation and reimbursement. There are many clinics who have shown interest in providing similar services in their communities but the major stumbling block seemed to be lack of credentialing standards for CAM providers in some states, lack of licensing laws for CAM providers in some states and lack of access to Medicare and Medicaid reimbursement for services. To further expand integrated care settings I recommend attention to licensing laws in all states, credentialing standard consistent with the best available in each profession or discipline, access to Medicare and Medicaid reimbursement, access to all government health programs including student loan repayment programs. Thank you.

The Honorable James Gordon: Thank you. Jane Guiltinan.

Jane Guiltinan, ND, Natural Medicine Clinic, Bastyr University: Hello, thank you. I am a naturopathic physician and dean of Clinical Affairs at Bastyr University. My responsibilities include the oversight of the clinical training programs at Bastyr where we train Naturopathic physicians, acupuncturists and nutritionists. I have been asked to speak about integrative care from the training model prospective today.

Health care practitioners who train together have the opportunity to build understanding, trust and relationships that benefit their patients down the road. This integrative training model is exemplified by one of our programs called the Immune Wellness Clinic. We have been providing integrated CAM services to patients with HIV or AIDS since 1985. Most of these patients receive care from both their conventional provider as well as a team of CAM students and providers. Regular information sharing between CAM and conventional providers is an essential piece of this training and care model. By working with each other and with conventional providers in other sites students learn how to optimize the healthcare of their patients by integrating services. In addition to training CAM professionals, many conventional medical and nursing students spend time in our clinic familiarizing themselves with different CAM modalities. Again, this cross-training fosters relationship building, trust and knowledge about effective ways to integrate care across disciplines.

Why is Washington State so rich in CAM training institutions? First of all, Washington state has educational and licensing standards in place for many of the CAM professions. This allows CAM training institutions to focus on these standards, design curricula to meet the goals of training safe, competent, practitioners. Secondly, Washington state law mandates that insurance companies provide coverage for all licensed health care providers. The ability for people with commercial insurance to access CAM services helps to keep CAM institutions liable in this state.

Despite these advantages CAM institutions face serious challenges both in Washington state and throughout the nation. One is the fact that public Medicaid and Medicare programs do not provide reimbursement for most CAM services. Another is that CAM institutions receive no public funds for graduate medical education. I serve as a trustee on the governing board at Harborview Medical Center, which is one of the University of Washington's medical training sites. Harborview will receive over twenty five million dollars from public funds this year to subsidize its teaching missions. In contrast, CAM training institutions receive no funding of this kind. I believe these inequities must change if we are to realize the goal of integrated health care delivery in this country.

In conclusion, I urge you to support the following issues: equitable policies in public and private reimbursement for CAM services delivered by CAM professionals. Second, educational and licensing standards that promote quality CAM education and qualified professional CAM practitioners in all fifty states. Third, funding to support integrative training models like the Immune Wellness Clinic and CAM institutions as well as conventional medical institutions. And finally, to support equitable public funding of graduate medical education in CAM institutions, including subsidizing direct and indirect costs of residency programs in CAM institutions. Thank you very much.

The Honorable James Gordon: Thank you Jane. Fernando Vega.

Fernando Vega, MD, Seattle Healing Arts Clinic: I am a family physician in practice for twenty one years, currently at a clinic called Seattle Healing Arts. At Seattle Healing Arts we've had nineteen years experience of collaboration between MDs, psychotherapists, naturopathic physicians, acupuncturists, licensed massage practitioners, and at one time midwives working in close proximities. Each practitioner was in private practice. This experience includes having, sharing a room with all of our guests in the same room which facilitates daily exchange of views by impromptu consultations as well as co-management scenarios. This is an opportunity for all practitioners to get a glimpse of the, another professional worldview. Treatment in common chronic problems such as congestive heart failure, diabetes, arthritis and chronic fatigue [inaudible] collaboration. Different approaches are applied and all parties involved benefit from subsequent monitoring and observation of the outcome. However, most patients that come into anybody's office come from more subtle problems and lifestyle, lifestyle imbalances. That fits especially well for CAM providers.

Collaboration and integration doesn't occur spontaneously when practitioners are thrown together randomly. It requires a willingness to share prospectives and, more importantly, a willingness to receive another viewpoint while suspending one's own prejudices at least temporarily. Proximity requires a tolerance at least if not friendship. Worldview often conflict and a strong container is needed to hold the process. The practice setting at Seattle Healing Arts may not be easily reproducible because of those requirements but it has served as an experiment in providing opportunity as a tool for observation and examination of the potential for CAM collaborations.

I'd like to share with you some examples of what might otherwise be very difficult and impossible to accomplish in another setting. Treatment of early acute epidedemus [inaudible] with visceral manipulation and lymphatic drainage by licensed massage practitioners; treatment of common acute conditions such as sinusitis and back pain, asthma, eczema, but close follow up of outcome with a fall back plan for conventional medicine, nasal specifics under anesthesia.

My pitch is not necessarily for integration or new modalities under the current health care system as much as integrating practitioners of other professions into the health care arena. I have learned that acupuncture may be taught to a medical doctor but MDs would never offer what acupuncturists and practitioners of traditional Chinese medicine have to offer. Integrating the [inaudible] practice would improve such care, but under these could never offer what midwives could do as a culture. I wanted to underscore what the general [inaudible] statement was about our health care, maternity health care being upside down. Similarly, naturopathic medicine hasn't been a central.

The Honorable James Gordon: Excuse me, time is out so if you want to.

Fernando Vega: Okay.

The Honorable James Gordon: Okay.

Fernando Vega: Okay.

The Honorable James Gordon: I wanted to say just a couple of words. One is as we go along through the day and I think through the rest of the day and tomorrow I'm really appreciating the tremendous growth and sort of sensitivity, and sophistication, and responsiveness of integrative medicine CAM practices in this area. And so it's wonderful to hear it. Also though I do hear the note Don Taylor in your story and your concern. And I'm wondering if you have a specific, I understood what you said about placebo. But, you see a way to, on the one hand permit the development of responsible CAM practice, and on the other hand to address the kind of issue that you're talking about. Do you have some thoughts about that? And here, won't you take the mic cause it's such a poignant story about your story.

Don Taylor: Before the blue ink when it was a five minute presentation and not a three, there's a fairly broad sort of understanding in the conventional community that if you equate something with placebo that's now worthless and to be discarded. That's not really necessarily the case. And particularly I think in these cases showing how large the placebo effect is is something important here. That really does demonstrate something. It's not something just to be tossed away here. The Honorable James Gordon: Right. I think, I think we understood that.

Don Taylor: And getting people to actually measure that rather than saying well I just can't. I'm dying, we can't measure anything, we can't do those things. Those things will let someone try to be able to make a reasonable evaluation of these things.

The Honorable James Gordon: But the other side as well, the story about your friend.

Don Taylor: Yeah.

The Honorable James Gordon: Do you have any thoughts about what kind of, how to address that kind of situation?

Don Taylor: The opening paragraph saying that the collection and publishing of standards showing whether something is effective or not. It may well be that zero gravity does kill cataracts but if that's not the case then you didn't risk breaking a hip on your trampoline when you're eighty.

The Honorable James Gordon: Thank you.

Male Participant: Yes, Dr. Guiltinan, could you clarify your comments about GME funding. Are you saying that, that's generally money for residency training and not undergraduate medical education? So are there residency programs that aren't being funded and sharing in those resources or are you just talking about undergraduate students?

Jane Guiltinan, ND: No, yes there are residency programs that are not being funded currently at all of the naturopathic colleges and at Bastyr in the acupuncture program.

Male Participant: Thank you.

Female Participant: This question is directed to Dr. Vega. Was your association or your integration of all of these professionals in your clinic born of necessity, the sharing of the office or was it born of a deliberate decision when you began your practice?

Fernando Vega, MD: It was born of a, of an idea of a vision for lack of a better word. It started out kind of accidentally with an acupuncturist starting at the office which brought in patients who had a different prospective, a different prospective on health care, and actually required more, demanded more of what they've already seen. This brought on students from Bastyr as well as naturopathic in the early eighties. We've also had our share of other NDs who've had. As you know there's a discrepancy in funding so MDs essentially carried most of the economic weight so the idea of integration actually was economically sound.

Female Participant: Don Taylor?

Don Taylor: Yes.

Female Participant: You mentioned about the study of placebos and it's kind of been the course of, well it's just a placebo effect. It's like you're breaking that traditional, you know, impression. Do you have the mechanism to study placebo research? Do you have some research programs in studying the placebo effect? At the moment I'm involved in an unconventional application of a conventional treatment and we are wrestling with trying [inaudible] tease apart what's chemical and what's placebo and where is the line between those. And I've spent a year working on that. And I think in most cases with some creativity, and some work, and some dedication it is possible to tease these apart and to be able to see these things.

Female Participant: So it's conceptual right now is it, or?

Don Taylor: No, we--

Female Participant: Actually doing.

Don Taylor: No, I have file up subjects. I have subjects in the field now.

Female Participant: I'll be interested to hear more about it.

Female Participant: Also directed to Don Taylor. I'm sorry, somewhere along the line I don't understand what facility you were associated with from Oregon but I have to say that I'm just sort of, understand some of your concerns. But as providers I think our goal is always excellence. I don't think we'll ever reach perfection. And so you answered part of my question about. My question was, do you have ongoing or anticipated research to address your concerns about the efficacy of CAM procedures?

Don Taylor: I don't practice CAM. I can't address that. But my research involvement, I thought I could contribute what I thought would be a way for patients and practitioners to be able to more effectively evaluate these treatments by introducing some sort of standardized form that people would be able, something that would not be dozens of pages for someone to work on but some simple standardized way that could at least give you an idea. You know, if you were to come up against this, how much of a chance you might have of this being effective.

Female Participant: [inaudible].

Don Taylor: Portland State University. I don't know how that got lost.

Female Participant: Yes, I have a question. But also if you, even just on Medline, if you look up consort, the consort statement that was done, I think it was a very good attempt on researchers' parts to try to organize standards for randomized control trials and also for people to evaluate and trying to simplify that. So there are attempts in conventional medicine to work on that. My question is for anybody who wants to answer on the naturopaths or for the physician, Medicare and Medicaid reimbursement. We have a private clinic in New Mexico and about sixty to seventy five percent of our patient population is Medicaid and Medicare. And the problem always comes down for those of us who take thirty or forty five minutes with a patient and you get paid twenty-eight dollars. And then you have to have somebody bill for that, and you have to have the receptionist and the nurse that it's very poor reimbursement for primary care providers who do a lot of behavioral counseling or this.

And naturopaths, what I've been hearing from some of the patients that were presenting is, took an hour and a half with me, took a lot more time. Have you thought about maybe the down side of reimbursement with Medicaid and Medicare that a lot of us are dealing with as well for? When you take thirty or forty five minutes and the reimbursement is twenty eight dollars and they're also rejected it and you've got to resend it back, it's, it's a nightmare. How well that will work within your model, have you just thought those things through?

Cindy Breed, ND: I think that's a very good point. I think in the model that I'm in which is a community health center, probably some reimbursement would be better than maybe nothing at all and maybe there would be other ways to try to make up the difference there. But we do tend to spend, personally I spend an hour on the initial visit and generally a half hour on most follow up visits, although some maybe more like fifteen minutes. So, that's a good point and I don't know how we would want to work that out.

Jane Guiltinan, ND: I'll just say I'm, I'm somewhat familiar with your challenges given my work on a hospital board and the havoc that the Balanced Budget Act is wreaking with hospitals being able to stay in business and providers being able to keep on providing care. But what I'll say is that naturopaths would love to join you in the struggle to try to help fix the problems associated with Medicare [inaudible].

Female Participant: We'd be glad to have you.

Male Participant: What are the practices that succeed in getting licensing and credentialing in states that have adopted these practices?

Female Participant: If I understand your question, you're asking how did the states who got licensing standards do that.

Male Participant: Yes.

Female Participant: And that is a question I probably can't answer and would refer you to someone like Dan Mavriola or someone at the state level who could talk with you about specifically the standards and licensing issues in Washington state. However, it took a lot of years of talking and discussing and meeting with people who opposed licensing laws, those being either the type of person who does not want a licensing standard or the conventional medical system who is resisting all the licensing alternative CAM professionals. It is all of those people sitting down at the table and then negotiating out the issues, writing the legislature that was eventually passed.

The Honorable James Gordon: Thank you all very much.

Female Participant: One last panel before we take a quick break. If Judith Kaufman, Stan Lippmann, Valerie Sasson and Scott Barnhart would come up. Thank you.

The Honorable James Gordon: Welcome. Goodbye to those who have to go and welcome to the panel. So we'll begin with Judith Kaufman.

Judith Aileen Kaufman, Emerald City Healing Arts: Hi, thanks for having me. My name is Judith Kaufman. I'm an acupuncturist and Dental Hygienist and I'm a graduate of Northwest Institute of Acupuncture and Oriental Medicine. And an important part of my training was working in, in Harborview. I did a chronic fatigue clinic there to those international clinic HIV/AIDS. I worked at St. Vincent's Nursing Home, Forty Fifth Street Clinic, a methadone clinic, alcohol and drug detox clinic. And that was a very important part of my training. So that was my experience as an acupuncturist integrating that in my educational training.

I believe in a partnership approach to integrative and allopathic medicine. It's important to recognize the impact of lifestyle, diet, organic and whole foods and environmental exposure to chemicals and the social environmental issues. In a partnership approach free of fear and mistrust with the patient's best interest in mind would come with collaboration. The body is not a machine. The body has an intelligence and is extraordinary. The body can be a teacher and has incredible healing potential. Such an approach would honor the healing capacity and wisdom in the body. Dependence on medical technology is not the answer for prevention of disease. Taking control of health by making the right food choices, exercise, breathing exercises, education and simple home remedies for health care can be inexpensive ways for empowering ourselves to take the reign for our health. There are always factors in our life that we cannot be controlled, but the simple intention of wanting to bring more love and healing in our lives can be reflected in us inwardly and then thus outwardly.

Health is a presence of vitality and balance in understanding to grasp our personal path and the recurring themes that occur in our life. Each person has an inherent ability to heal and this is our birthright. I believe it is important for all practitioners allopathic and integrative to educate their patient and client and facilitate inner healing. I see access to helping the person in their own facilitation of healing, giving the person power to be their own healing physician. And we as the, the practitioners, we can help the patient facilitate their own healing. Thank you.

The Honorable James Gordon: Thank you. Stan Lippmann.

Stan Lippmann, PhD, JD, Natural Medicine Party: Hello, thank you for the opportunity to speak. I'm here representing the Natural Medicine Party today and that's something that I created this year in my run for the Attorney General. I'm on the ballot next week. Anyone can find more information at my website www.rebella.net. I am an attorney and before that I was a physicist. So although I'm not a, in the medical profession, I was personally impacted by an adverse reaction to a vaccine a few years ago which has led me down the path I'm on now, which is a little beyond the purview of this commission. Because what this goes to is the fact that the allopathic approach is not only not vitalist, it's actually with regard to the vaccination program anti-vitalist. That is, and there is slowly emerging consciousness, which is still beyond the general acceptable political pale, that the damage being done by the national vaccine program is astronomical. I believe it's responsible for a good maybe half of all chronic illness by the induced autoimmunity processes that are neglected.

So while I applaud President Clinton for establishing the commission, the President, the Governor of this state, Gary Lock, Bill Gates, all the powers that be are in the pockets of the the medical establishment with the backing of the Supreme Court and the AMA. This goes back for over a century and it is actually an actual conspiracy, which goes back even hundreds of years with the British genocidal smallpox policy. In fact, the threat to human and the life of this planet is, is very grave and we see that solely being revealed in the political process next week.

We see an resurgent candidacy, the Green Party, which is just the beginning of the breakdown in the faith of the general public. And what I'm trying to do to the public is to awaken them. I'm trying to awaken all of us to the reality that the, the whole paradigm in which we are living is false and that this, it's almost a primitive blood ritual that we, we do to our infants in terms of injecting mutant viruses and metals. For example, the EPA limits are exceeded by thirty times in a, in a hepatitis B exposure. And this is just one of the bureaucratic insanities going on.

Every week, everyday you find more stories in the news which all plug in the direction of what I'm saying is true that the actual damage being done is astronomical, maybe a trillion dollars so far. Just today the B cell research, you know, I know I'm out of time, but just to mention today's news for example the showing that the B cell, if you kill the B cells through medical allopathic treatment you can cure arthritis. And this indicates that this whole approach of stimulating antibodies is actually stimulating chronic illness and needs to be completely rethought. Thank you.

The Honorable James Gordon: Valerie Sasson, LM, Puget Sound Birth Center: I'm here today to describe licensed midwifery in the state of Washington as a model of integrative health care. Before I begin to discuss the successes we've enjoyed, the atmosphere that engendered those successes and the challenging, the challenges remaining, please allow me to introduce myself. I'm a licensed midwife in the state of Washington, trained at Seattle Midwifery School. Prior to becoming a midwife I graduated from Brown University and subsequently worked for many years in community health. My midwifery partner and I currently maintain a busy practice in Kirkland, just across Lake Washington from Seattle, attending an average of eight to ten home and birth center births per month. I'm a co-owner of the Puget Sound Birth Center, also located in Kirkland. And I'm here representing the Washington Association of Midwives, our state professional organization. And then also as you can plainly see I'm a midwifery consumer at the moment.

I will briefly describe the legislation, vision and practices that are responsible for the success of licensed midwifery in Washington and the ways in which this become a model of integrative health care. Free-standing birth centers represent an important milestone in midwifery in Washington. So I'll spend just a moment describing the structure and function of our birth center as well. You'll be hearing about the specifics of direct entry midwifery education, scope of practice and licensing requirements, third party reimbursement, malpractice insurance and quality assurance from my colleague so I'll touch on those just briefly.

Here in Washington state licensed midwifery has greatly benefited from a few key pieces of legislation. First and foremost, is the law under which we are licensed as autonomous practitioners and which describes our educational requirements and scope of practice. Second, is a vital piece of legislation initiated by our insurance commissioner, Deborah Sam, which ensures the availability of malpractice insurance for licensed midwives. Thirdly, we have the Every Category of Provider Act ensuring that insurance companies will reimburse representatives from every licensed health care field. And lastly, we have the Women's Health Referral act, which allows women to bypass their primary provider in selecting women's health care professionals.

In March of 1970, I'm sorry 1997 another analysis of the safety of home birth was published in the birth, in The Birth Journal. The author concluded that out of hospital birth is an acceptable alternative to hospital confinement for selected pregnant women and leads to reduced medical interventions. He describes four factors that must be present to ensure optimal outcomes, specifically, low risk motivated women, planning out of hospital birth, screened and attended by practitioners specifically trained in out of hospital birth with ready access to a modern hospital. I would add a fifth factor, tthat of access to willing and informed back up physicians and other health care professionals.

I cite this research because it provides an easy construct within which to discuss the extent to which licensed midwifery in Washington state has succeeded in becoming a model of integrative health care and the challenges we currently face. I'll leave the rest of this talk in with my packet so you can conclude. You can also visit us at our website which is www.birthcenter.com. Thank you.

The Honorable James Gordon: Thank you. Scott Barnhart.

Scott Barnhart, MD, MPH, Harborview Medical Center, University of Washington: Good afternoon Mr. Chairman, members of the commission. My name is Scott Barnhart and I'm the Medical Director at Harborview Medical Center. I wanted to talk to you briefly this afternoon about integration. Harborview Medical Center is a three hundred and fifty bed acute care hospital. We have approximately two hundred thousand out patient visits, approximately fifteen to twenty thousand adjusted admissions depending on who's calculating it on which given day. It is owned by the citizens of King County. It is run by the University of Washington School of Medicine under a long term contract. The hospital is the level one trauma center for the region and it also has a number of missions. But has a very large commitment to service to the uninsured.

We have, I think, taken many steps along the path of integration. We have massage therapy. We have acupuncture. We have affiliation agreements that have included the training of students in those areas. We also have a number of research activities that range from seasonal effective disorder, looking at the efficacy of light therapy. We are studying the impact and utility of virtual reality inpatients with pain in the burn area. We have a very strong pastoral care of program and training program that I think really deals with some of the mind body relationships. And we have program, another research program which is using magnetism to stimulate the brain in a randomized controlled fashion to see whether or not it can reduce the effects of depression.

With all of this, I think when you look at a teaching hospital we are an important community research both in terms of teaching, we provide clinical care and we do research. And as we talk about this issue of integration. I would like to make a very strong plea that you strongly favor the increase in dollars for research cause I think you're the best way to bridge this gulf that many people say is there. And I would say is there and acknowledge that is going to be through very strong research programs. Thank you.

The Honorable James Gordon: Thank you very much. Let's begin, Tom at your end.

Female Participant: Dr. Barnhart, I commend you on the research that you're doing and your inclusion of licensed massage therapists and acupuncturists. How much do you collaborate with Bastyr and has there been any consideration of, of perhaps residents cross-training, residents going over to Bastyr and doing some training and residents from Bastyr coming over to your place to do training in patient?

Scott Barnhart: I'll look to Jane. I don't believe we yet have an affiliation agreement. We're still working on that. I think we're, you know, if we were to look at the training at this time, you know, we do have students that have come from Brenneke School of Massage and my own. We are discussing within the School of Medicine, there are a number of faculty members who are discussing the training exposure of medical students in terms of complementary and alternative medicine. At this time there's really not been discussion of exchanging residents.

Female Participant: For even part-time exchange?

Scott Barnhart: Right, not even. And I think one of the things that's important to recognize is that if you really look at say the accreditation requirements residencies. I mean they're quite strict in terms of what they require and how time is spent.

Female Participant: I'd like to thank Dr. Lippmann for introducing a controversial concept that I think needs to be discussed and looked at. I missed your full website. But one of my questions is, is part of your website education beyond your campaign? Is it perhaps case studies of vaccine damaged individuals? Or what is accessible at your website?

Stan Lippmann: Actually the website is rubella.net which I started a few years ago and one of the main sections is called the Rubella.net News and that gives the latest news stories on the vaccine controversy. It's really a weekly occurrence that a major periodical, the New York Times, Time Magazine will be discussing topics such as the Gulf War Syndrome. Last week it was White Cell Jacob Disease in Polio Shot. Week before that it was New Yorker Magazine had a Yanamami tribe in the Amazon was wiped out by a measles program and so on. So this is something that over the past couple of years, three years of my personal involvement has grown exponentially. It's still a little bit below the radar screen but one of the points of my website is to be a base for all the information on the web. And again there are many, many, many websites that I point to from my website there. So.

Female Participant: Thank you.

Female Participant: This is for Dr. Barnhart. Is your massage therapist and your acupuncturist on staff or are they contracted?

Scott Barnhart: They do have a, they are members of the medical staff. They actually come in I believe largely as volunteers cause they're usually are training students so the faculty come in. But they, the ones who come in are credentialed on the staff.

Female Participant: They're credentialed on staff but how are they paid? That's my question.

Scott Barnhart : They're paid through the school.

Female Participant: Through the school. And is there a, are you developing a curriculum in, for teaching your residents in complementary and alternative medicine?

Scott Barnhart: No.

Male Participant: Mr. Barnhart, your institution has a national reputation for producing leaders in end of life care, people like Randy Curtis, Gordon Rubenfeld and others. Are you, the activity here in the area with CAM therapy, your relationships with Bastyr and the [inaudible] of expertise in end of life care. Is there any kind of activity where relating CAM and end of life care at your institution?

Scott Barnhart: You know I don't want to speak cause I don't fully know all of Randy or Gordon's research. And a lot of the work that they've done, you know, much of it is, is in the setting, the intensive care unit setting. We are an acute care hospital with the case mix is about 1.6. I mean, the people here are extremely ill and my, my guess is there's not that much interaction. But I can't say for sure.

Male Participant: Thank you.

The Honorable James Gordon: Okay, thank you four very much. We'll take a fifteen- minute break and then we'll come back and we'll have the next panels.

White House Commission On Complementary And
Alternative Medicine Policy

October 30, 2000
4:40-6:15pm

[Tape 6]

Male Participant: We're going to begin again.

Female Participant: Would the following panel please come on up? Leah Kliger. Could everyone please take their seats and the commissioners return to the stage. Thank you. Would the following panel please come up? Leah Kliger, Brenda Loew, Robert May, Terry Courtney. And also at this time if the following panel would also come up? Sue Vlasuk, Diana Thompson, Houston LeBrun, Heike Doyle. I apologize if I'm really killing people's names here. I'm trying my best.

The Honorable James Gordon: We understand it's nice to have, it's nice to have breaks, but we thought we'd try to start by about midnight tonight so we want to. Great. Leah Kliger.

Leah Kliger, MD, Evergreen Community Health Center: Hi, good afternoon. My name is Leah Kliger, I'm director for Integrative Medicine at Evergreen Hospital and Health Care in Kirkland, Washington, about fifteen miles from downtown Seattle. I want to talk with you today about how, through educational grants and economic incentives, you could provide access to integrative education and training at the local community level. This can help our health care system, our physicians and nurses and other community hospitals forge better alignment between the majority of our medical staff who currently are not local supporters of CAM integration and hundreds of local CAM practitioners. We need new and different language that encourages participation, not words and actions that raise heckles.

In 1997 we discovered that sixty-nine percent of our physicians felt they did not have the knowledge to communicate and confidently talk with their patients about alternative medicine, nor to appropriately refer to CAM practitioners. Eighty-eight percent of our physicians said they wanted more information and access to credible information. Based on these needs, Evergreen has underwritten a variety of activities including continuing medical education sessions, case conferences and workshops for caregivers and the entire community. But we need your help. Here are our recommendations.

1) Make a combination of educational grants, tax credits and vouchers available to community hospitals, to our medical staff and to local CAM practitioners. These would pay not only for continuing education sessions and workshops, but would also provide economic incentives to the physicians, nurses and community CAM providers who attend them. For example, we want to develop two-way training programs whereby conventionally trained doctors, nurses and CAM practitioners teach each other about specific conditions and approaches and learn new language and philosophy. Grants, tax credits to physicians and CAM practitioners in private practice and other incentives would make it financially feasible for learning to occur.

2) We ask you to fully fund CAM research studies that make it easy for community hospitals and physicians to participate. Our pediatricians have indicated an interest in participating in CAM research studies about pediatric asthma, yet at the local community hospital level we simply don't have the money or resources that make it viable for us to participate in those research studies in a meaningful way.

3) We'd like you to develop a no-cost or low-cost way to have simple electronic links to credible CAM sites that can be then easily linked to our hospital and physician sites, and

4) we want you to quickly establish an evidenced based national formulary for botanical medicines. On behalf of the three hundred and sixty thousand people we serve, thank you very much.

The Honorable James Gordon: Thank you, too. And thanks for the very direct and pointed recommendations. We appreciate that. Brenda Loew. So be it. Her chi ran out. Robert May.

Robert A. May, ND, Alternare Health Services: Thank you. I'm glad to be here today to be able to present this material to you. My name is Bob May. I'm a Naturopathic physician, a Bastyr graduate, a former Bastyr clinical faculty member and currently the Clinical Director for Alternare Health Services, a CAM preferred provider network here in Washington and Oregon.

Alternare has developed and maintained CAM provider networks in the northwest for over five years beginning with the Washington State legislative mandate. We currently have approximately eighteen hundred providers who are credentialed with our network in Washington and Oregon, and these include chiropractors, acupuncturists, massage therapists, Naturopathic doctors and dietitians and nutritionists.

In addition to credentialing CAM providers Alternare also conducts regular quality assurance procedures that include surveys of consumers and providers, site visits and provider education and recredentialing. Some elements of Alternare [inaudible] experience may offer a model for the development of federal policies. From our beginning we have developed provider policies that have been based upon the NCQA guidelines for provider credentialing. These are the same guidelines that are used for managed care organizations with any type of health care professional. The process includes primary source verification of both educational and licensing for each provider and where applicable, it also includes specialty certification and any national certification. In addition, providers must meet minimum requirements for malpractice and liability insurance as well as undergo state patrol claims made and complaint evaluations, and the entire process is repeated every two years. In our experience, the NCQA credentialing of CAM providers offers a solid initial level of quality assurance and public safety and a foundational step towards integration and inclusion of CAM providers in the mainstream health care.

The most essential element for initial provider credentialing is state licensure. Inclusion within the Medicare and Medicaid system which facilitate licensing efforts for CAM professions around the country and, in addition, licensing is usually a prerequisite for malpractice insurance. Another element that we would have found very essential to credentialing in this mode is clinical training as an essential part of professional CAM education. And that, we feel that if the federal recognition of NCQA standards were to be adopted it would further this process across the board.

I would just like to mention one other thing and that is, that the CPT coding system, which is sort of the language that communicates what providers do in this country has never been designed with CAM providers in mind. And that should be something that should be addressed so that what is done is communicated accurately among all the different professions.

The Honorable James Gordon: Great, thank you very much. Terry Courtney.

Terry Courtney, LAc, Bastyr University: Good afternoon, I'm Terry Courtney. I'm chair of the Acupuncture and Oriental Medicine Program at Bastyr. I'm also a licensed acupuncturist. The availability of reimbursement for acupuncture significantly increases consumer access, choice and increases integrative and collaborative health care options for consumers as well. In 1997 the NIH convened a panel of experts to examine the scientific data on the use of acupuncture. This expert panel recommended the removal of financial barriers by urging insurance companies, federal and state health insurance programs, including Medicare and Medicaid and other third-party payers to expand their coverage to include acupuncture.

What is the current status of acupuncture reimbursement right now in the U.S.? For acupuncturists, 1) there is no Medicare reimbursement. 2) Medicaid does reimburse in some states for chemical dependency treatment alone, and 3) third party private pay is still determined at the company's discretion. It is not mandated coverage.

What are some of the barriers to increasing coverage for consumers?

1) Most peers want cost effectiveness studies. At this time, we only have limited funded research available. As a result, peers still see acupuncture as an add-on charge rather than as a potential partner in reducing overall costs.

2) As Bob May just mentioned, there are diagnostic differences between acupuncturists and the insurance world. Acupuncturists cannot use a western medical diagnosis unless predetermined by another provider. For example, a patient with migraines may have resolved the condition with acupuncture but because the acupuncturists don't use -- had to use a code of headache rather than a code of migraine acupuncturist efficacy in treating this case is missed in insurance utilization data analysis.

3) Medical necessity is often times a requirement for insurance reimbursement. If physicians are uninformed as to the benefits of acupuncture and if they are the ones determining medical necessity they may not support its inclusion in treatment plan. The second challenge is that medical necessity for coverage assumes that a patient is already ill. It does not allow for preventative therapy, which is the strength of our medicine.

What are the next steps?

1) There's a need for more funded research regarding clinical outcomes and cost effectiveness. Following the recommendations from the NIH panel acupuncture should be involved in the research design.

2) Insurance data banks need to evaluate how to analyze the acupuncture visit codes in order to not miss pertinent data due to restrictions and diagnostic codes by practitioners, and

3) Continued CAM education opportunities for other providers is necessary to increase the awareness of acupuncture's role and medical necessity as a stipulation for inclusion of acupuncture in the reimbursement arena.

A minor point in closing, we must also work to complete access to acupuncture in all fifty states. Eleven states remain right now which do not legally recognize acupuncture and or our missing statutory language. Thank you.

The Honorable James Gordon: Thank you. Questions. Joe starting at your end.

The Honorable Joseph Fins: I have two sort of operational questions, one are, one is for Dr. Kliger. Do you have any ideas on how to create a formulary?

Leah Kliger: Well, since Dr. Low Dog is on this panel, she could probably speak more eloquently than I can. I also want to just clarify something. Somehow along the way. I have picked up a medical degree and I'm actually a recovering hospital administrator. So let's do away with the MD. Actually, there are a number of ways we could create that national formulary, and I think working closely with the schools of pharmacy in this country, a number of the schools of medicine and experts like Dr. Low Dog. Something like that could probably be put in place in, without too much difficulty. There are, there is the, there's actually a lot of very good information from Europe and there's some very good information in the United States that make that very do-able.

Male Participant: For, for Dr. May. How do you bill? Do you have a comparable sort of internal CPT code that you use? And if so, could we see it and perhaps examine it?

Robert A. May: We use the standard AMA CPT system. So many of the codes end up being kind of bent, twisted and borrowed to approximate the service provided by CAM providers. It has produced its own share of challenges in the billing process because the code will initiate a certain response within a health plan and when you try to track it back it, it, it, it, there's a discrepancy there.

One additional element just that I wanted to mention about codes to keep in mind is that, one of the facts, one of the factors that I believe the public has really recognized in CAM care that is not addressed in the CPT code system is the amount of time that the provider spends with the patient or the client. And that could be something that a CAM panel could really look at in developing specific codes for these services.

Male Participant: Thank you.

Female Participant: [inaudible] I'd like to address this to Dr. May. Our office has been credentialed with Alternare since its, I think since its formation, and to this date there hasn't been one contract available to participate in. So I'm asking you, what are the barriers that you're, you're running into for contracting for CAM services?

Robert A. May: I'm trying to think of a witty comment to make about the vagaries of the health insurance industry and the changes and movement there that are really outside the realm of our network's ability to control. Business decisions made by health plans that contract with network, such as ours, really occur in another world that I'm afraid I won't try to address. And probably won't come up with a witty comment about either.

Male Participant: Dr. May, do we have a critical mass of naturopaths throughout the country? I'm sure we do not. How then do we get states to decide to go ahead and license an entity they're not familiar with, don't see, know nothing about?

Robert A. May: I think it's a question that deserves a lot of focused study, but one of the models that can be used in addressing that is that with a region like the northwest and even some of the New England states that have established CAM licensing regulatory statues and laws on the books. It is not a real leap to extend that model or those standards to a state that does not yet have the critical mass of providers. Some states right now, I believe it may be Alaska or Hawaii, one of them, requires a license from a state that does license the providers. There are ways to work around that but to uphold the same standard for credentialing.

The Honorable James Gordon: Thank you.

Male Participant: May I?

The Honorable James Gordon: Sure.

Male Participant: Is it Dr. Kliger?

Leah Kliger: Call me Leah, how's that?

Male Participant: Leah, thank you. I do think your recommendation of college of pharmacy is indeed an excellent source. They are right now the centers of knowledge and they're the ones receiving the grants from NIH to do the specific research so. I do know that they have a very good base of knowledge for these botanicals. Please comment.

Leah Kliger: I'd like to comment on that, I think they're one of the sources of information. I think there are a great many other sources that would need to be consulted with in order to develop that national formulary. There are some particular biases that we all, in our particular professions have. And in order to make sure that all voices are heard we'd need to look across the spectrum of both organizations like the American Botanical Council, the Herb Research Foundation, physicians, the Rosenthal Center and Columbia University plus schools of pharmacy.

Male Participant: CRN, Council for Responsible Nutrition?

Leah Kliger: Sure.

Male Participant: I had a question. How, how is the program evolved and and why do you think you're in the hospital, connected to the hospital? What's, if you just very briefly give us a sense of how and why your program has grown. And why, in a perhaps second question, why in a climate when many of the hospitals I go visit say well we're interested in CAM but herbal therapies scare us mightily? Why do you think you're moving in this direction? What's, what's happening?

Leah Kliger: Well, a couple of things. As you know because you've keynoted a couple of our symposia, Evergreen Health Care includes not only hospital but thirteen community based programs, a hospice, a home health center and has always seemed to have gotten the idea that we exist to serve the community. And because we've also done a number of studies that indicate well over fifty percent of the people in our service area use complementary and alternative medicine our board and our community advisory said, yes, we do need to take a stand. We do have policy statements written into the governing board policy that indicate individualized care that take into account body mind and spirit will be part of the service that we provide.

That said, we do a lot of education. We've spent a lot of money on education and now we, as I indicated, we need your help with that. However, someone mentioned earlier, I think it was Jane Guiltinan from Harborview, as well as the one from Bastyr, who talked about the Balanced Budget Act. And we're pretty much affected, we're very affected by that Balanced Budget Act as well, by the Balanced Budget Act, the Medicare Balanced Budget Act. So at a time of scarce resources, I actually find that our budgets that have been designated specifically for integration of CAM activities continue to shrink. And I have actually been challenged now in the next year to go and find at least half of my budget from sources outside of the hospital. So it's not an easy task. We continually face uphill challenges, and it seems as though with our integrative medicine task force their recommendation, our recommendation is continually more and more education and rubbing elbows.

The second piece about the botanical medicine piece, what we know is so many of our physicians get asked these questions all of the time. And so they're saying, we don't know what to do. We need to know what to do in order to be responsible physicians. Hence, help us figure out what the best botanicals are. We need a national formulary.

Female Participant: Just a quick comment. I mean, and one of the reassuring things for physicians, I think, is that eighty percent of the sales of botanicals in this country only consist of twenty botanicals. I mean, so there is a lot that are used, but eighty percent are only of twenty botanicals. And so it's not a daunting task to really provide a substantial amount of information based, and most of those twenty actually have a fair body of research, some good and some bad for them.

Leah Kliger: And it would be really wonderful if at a national level those twenty were made known and then physicians would, all the way from the AMA through the American Holistic Medical Association, through the schools of pharmacy, would recognize the efficacy of those twenty.

The Honorable James Gordon: Thank you. I, one of the things I wanted to say is that just sort of really to tell the commissioners is that as with Harborview, Evergreen also is one of those hospitals that really has stepped out and I did participate in a conference with them. It's quite wonderful. It's quite impressive the way you've mobilized people. And I would, if other thoughts come to you and if there are people, other people in the medical community here, about some steps that you might recommend or pathways for conventional hospitals to open up in the way you have, I think that would be very helpful as we move ahead. Thank you very much. Next is Sue Vlasuk.

Sue Vlasuk, DC, DABCO: Good afternoon.

Male Participant: Good afternoon. Could you tell us what DABCO stands for?

Sue Vlasuk, DC, DACBR: Well, that's a mistake actually.

Male Participant: Michelle is very curious.

Sue Vlasuk, DC, DACBR: A different collection of letters. That's actually an error. DACBR, Diplomate American Chiropractic Board of Radiology. What is there is incorrect. I am a chiropractic physician. I've been asked by the Washington State Chiropractic Association to make these comments. Also as alternate delegate to the American Chiropractic Association, I also represent those thoughts. And I also have been asked to speak specifically on the issue of reimbursement related to chiropractic.

So the things that have changed over the many years, well thirty years that I've been in practice, there was not much insurance. And I've heard comments made of other CAM providers that don't necessarily have the insurance coverage that chiropractic has right now, but there are problems still as was mentioned by Dr. Low Dog. And these problems, to summarize, even though you exist in a system are still severe barriers to an individual trying to seek an alternative method for their health care needs. It is an actual barrier to them because they have to pay twice. They have to pay for their health care insurance and then they have to pay out of their own pocket to go seek whatever alternative care they want. So some of the barriers, whether they exist in the system or not, I'm speaking from one who does exist in the system. A gatekeeper is a significant problem.

You're asking someone who is not necessarily familiar with the method to make a recommendation. It delays the care, it increases the cost and it decreases the likelihood that that referral will be made. Second, the coverages are frequently very limited. They may not include the full scope of what the CAM provider is authorized by state law to do. Just an arbitrary decision--we will pay for one thing but not the other. And another problem is we may pay for it but we're not going to pay for it at the same level for the same service that we would pay another provider, like forty percent less just because the degree is less. And also down-coding and bundling that I'm sure a lot of physicians have. And capping services too.

So what would be the recommended methods of recovery for this would be legislative and regulatory. And we're looking for direct access without a gatekeeper according to the full scope of practice in each state and like reimbursement for like services so that the patients don't have to pay twice to get the kind of health care that they wish to have.

The Honorable James Gordon: Thank you very much. Diana Thompson. Houston LeBrun.

Houston LeBrun, LMT, American Massage Therapy Association-WA Chapter: Good afternoon. I'm Houston LeBrun, I'm currently the President of the Washington Chapter of the American Massage Therapy Association. I'm a past national President of the American Massage Therapy Association and also an educator in Washington at the Brenneke School of Massage. I understand there hasn't been a great deal of LMTs before you today so I'll give you a little bit more background than a specific topic.

The American Massage Therapy Association currently represents over forty three thousand massage therapists and in the state of Washington more than three thousand. Currently there are twelve thousand LMTs in the state of Washington or plus. And the AMTA is currently affiliating with several organizations such as the Commission on Massage Training Accreditation, the National Certification for Massage Therapy and Bodywork Association and the AMTA Research Foundation, the AMTA Council of Schools.

One of the issues that I want to focus on is research and the American Massage Therapy's Research Foundation. Currently we, the research foundation holds the most complete database on massage therapy in this country and also has created a research agenda as of 1999. Both of those entities if utilized by the National Institute of Health would give us better access to the research that currently does or does not exist on massage therapy in this country. Often massage therapy has to ride on the coat tails of other research due to financial costs as well as the limited perimeters of research base that massage therapy can provide due to the fact that it's very difficult to provide imitation massage. So once the body is, often once the body is touched the process takes place, so.

Another issue is, the Commission on Massage Therapy Training Accreditation is currently seeking USDE approval and COMTTA is the most thorough body in regards to evaluating and accreditating massage therapy education institutions in this country due to the fact that their facilitators. And their managers for site visits are all practicing massage therapists and or educators in current institutions. which does not exist in other accreditating bodies in the country. And so in other words, increasing our ability to evaluate proper curriculum continues to be a challenge and one that COMTTA is serving this country very well with. Thank you.

The Honorable James Gordon: Okay, thank you. And Heike Doyle please.

Heike Doyle, LM, Puget Sound Midwives & Birth Center: My name is Heike Doyle. I'm a licensed midwife in Washington State. I'm a certified midwife nationwide. I have graduated from the school, midwifery school here in Washington State in Seattle and I've been in practice for twelve years. I have practiced in states where midwifery is legal and recognized and integrated and I have practiced in states where it is illegal and you might go to jail if you transfer a woman to the hospital. I can clearly say looking at research and my own experience, women get better care in states where midwifery is legal. Less babies die and women get much better care.

I'm here to present some information on reimbursement. We had, what has worked for us is we have three fabulous laws that our legislation has put in place. One is the direct access law. We don't have to go through the gatekeeper any more, which has significantly improved access of care especially for low income women who don't have transportation so they don't have to go see a physician before they can even come to us.

The second thing that we have like before we had the Every Category of Provider Law meaning insurance companies had to cover some providers from each licensed medical profession. Reimbursement coverage was very spotty. Now that we have that our midwifery has changed and has moved more into mainstream women and has gone away from, you know, the counterculture on the whole range. And the people that were willing to pay out of pocket in addition to their health insurance if they did have it.

The other thing that was I think the key issue for midwifery care to move into reimbursement is the mandate to have medical liability available for practitioners. That got us in the door with insurance companies and also we sat down and we talked to each other and we learned from each other like, what do you guys need from us and what can you give to us? So that was fabulous.

What has not worked is the third party payers that have headquarters outside Washington State are not as willing to negotiate with midwives because they're not aware of the standard of education and the standard of health care here in Washington State. The other thing that hasn't happened is reimbursement in Washington State is absolutely inadequate. We get OB care less than seventeen hundred dollars for nine months of care including delivery, prenatal care and postpartum. While physicians in hospitals get up to eight to twelve thousand dollars for the same services with less personal attention and for the same outcome. Thank you.

The Honorable James Gordon: Okay, questions? Joe, you want to start?

The Honorable Joseph Fins: Yeah, on the financial theme from Ms. Doyle. What's the malpractice cost for a midwife per year and what is it for an obstetrician in in this area?

Heike Doyle: I don't know what it is for an obstetrician. For a midwife it's a minimum of twenty four hundred a year even if they just do one birth and after you've done twenty four births you have to pay a hundred dollars per birth. That will significantly increase next year [inaudible].

The Honorable Joseph Fins: And how much coverage does that buy you?

Heike Doyle: That covers one million three million.

The Honorable Joseph Fins: One three, okay.

Heike Doyle: Yes.

Female Participant: I am interested to know is there not a national licensing for, for this?

Female Participant: No, [inaudible].

Female Participant: There is a national licensing for certified nurse midwives who primarily practice in hospitals. There is a state by state licensing mechanism or no mechanism for direct entry midwifes. So the states that have licensure also have educational requirement which improves care.

Female Participant: Dr. Vlasuk, I'd like to ask what would you like to see as a minimum standard of care each patient could expect as they enter a chiropractor's office across the United States?

Sue Vlasuk, DC: A standard of care?

Female Participant: Yes, a minimum that each patient could expect when they enter a chiropractic office.

Sue Vlasuk: I would expect that a thorough history would be taken and a good physical exam directed toward their complaint and whatever care turned out to be necessary based on that. I, I don't think you're asking about how much care are you?

Female Participant: I'm asking this question because I'm sure you have the same experience. I've referred patients across the United States and they can go into other offices and not get their spine checked and an adjustment but they can get a series of modalities and a massage and so forth.

Sue Vlasuk: Oh.

Female Participant: I'm asking you what is the minimum expectation every chiropractic patient could have upon presentation.

Sue Vlasuk: That is a tough question. Definitely, the history and the physical examination and the hands on manipulative treatment--the spinal adjustment, whatever you call it, and the other things are ancillary.

Female Participant: Thank you.

Female Participant: Thank you for your presentation. When you are working in an underserved area midwives in Washington is there a reduction in fee for your malpractice insurance.

Heike Doyle: No.

Female Participant: There is no compensation for the fact that you're working in an underserved area?

Heike Doyle: No, there is not. What is available is school grants that you can work off if you then work off in an underserved area so it helps you pay for your education. That is available.

Male Participant: On the question of direct access, I'd like to just raise a thought, if we are not working with the idea of a primary care physician, is it your speculation or experience that the consumer is still looking for some kind of coach, or counselor, or consultant to work with as he or she pursues a variety of modalities to try to solve ones own health needs?

Female Participant: Are you asking me?

Male Participant: That's an open question to whomever would like to answer.

Female Participant: If I could reply I would like to.

Male Participant: Thank you.

Female Participant: Yes, I think they are looking for a coach. However you've probably heard in prior testimony that you have a whole different approach of someone who wants to maintain health is looking for a little different type of coaching than how do I quit being sick.

Male Participant: I hear that.

Female Participant: Yes.

Male Participant: But you do still see the legitimacy of one consumer selecting a coach?

Female Participant: Yes, I do see that legitimacy very much so. And on the other hand of that this, this reimbursement issue that we're talking about actually keeps people from being able to make that decision. No, they are shunted into the tradition that their payer will pay for. And so they don't necessarily get to seek the kind of coach [inaudible].

Male Participant: I realize that. But in the absence of our present system it's helpful for me to hear that you, you think the consumer may still prefer to choose someone with whom to work.

Female Participant: I'm certain of that.

Male Participant: Yeah.

Female Participant: Absolutely.

Male Participant: Thank you.

Heike Doyle: I have a lot of clients that have a primary care provider and midwifery care takes care of everything that has to do with child birth, pregnancy and the new born during that ten month period. And if there is anything outside of that they go back to their primary care provider. And then, you know, I work in conjunction with the primary care provider which is the beauty of integrated care. We call each other and say this is what's going on what do you think and it really gives wonderful care to the women. So they do go back to their primary care provider.

Houston LeBrun: Yes, I think that in massage therapy is very involved with a scope of practice and staying within that scope of practice. So I believe that people are looking for a coach whether it is through an injury or towards a wellness modality. And I think that just as a physician would refer because they are beyond their scope of practice with massage. They don't, they don't have the scope of practice with massage that a massage therapist would have. So a massage therapist should be referring back to the primary care practitioners.

The Honorable James Gordon: I have a couple of requests actually. One is for you, Houston LeBrun. If the AMTA, and I'm asking you as a state representative, could give us whatever information they have about cost effectiveness studies. The only ones I'm really familiar with are Tiffany Fields, but I assume that there are others as well.

Houston LeBrun: There are several Tiffany Fields are of course the most wide ranged at this point. But there are several through the AMTA Research Foundation and I'll have them sent to you.

The Honorable James Gordon: That would, that, that would be great. A question, quick question about midwifery. What is the training? Licensed midwife training can be a whole variety of different things I assume?

Heike Doyle: In Washington State, there is a law on the books that clearly describes the requirement to sit for the state license.

The Honorable James Gordon: I'm sorry, it's what?

Heike Doyle: There is a law that clearly describes the requirements in order to sit for state boards. So it tells you, you have to attend a licensed school, licensed by the state. You have to be involved and deliver a hundred babies before you can even go and sit for the board. So there's a really clear measure on how many practical hours you have of the preceptor and how many hours you have to have theoretically in a formal education setting. The Honorable James Gordon: How, how many states have licensed midwifery as opposed to certified nurse midwives?

Heike Doyle: I'm pulling this out of my hat. I'm thinking there is licensed probably about seventeen now.

The Honorable James Gordon: Seventeen.

Heike Doyle: That have licensed midwifery.

The Honorable James Gordon: And the data that you gave, again this is a similar question. If, whatever you could do to help facilitate bringing us data about cost, cost effectiveness, malpractice, etc. whatever you have for licensed midwives would be very helpful.

Heike Doyle: I left a packet upstairs that has several, that has several studies on cost effectiveness of midwifery care in comparison and outcome studies.

The Honorable James Gordon: And is there now a [inaudible] between licensed midwives and certified nurse midwives?

Heike Doyle: Well we're dancing with each other and sometimes it goes better than others.

The Honorable James Gordon: Okay.

Heike Doyle: So I think in this state it works.

The Honorable James Gordon: Any guidance you want to give us as we approach the whole, the whole issue of making recommendations. For example, as a licensed nurse, as a licensed, sorry as a licensed midwife are you covered by any insurance here at all?

Heike Doyle: Yes, actually after the Every Category of Provider Law we started sitting down with the insurance company. I [inaudible] have a contract with about ninety five percent of all insurance companies in Washington state in my area. So-

The Honorable James Gordon: Could you give us since not necessarily here but of a, of some kind of model that would make sense to you for coverage.

Heike Doyle: I will be glad to.

The Honorable James Gordon: Okay, great. Thank you very much.

Female Participant: Thank you.

The Honorable James Gordon: I'm going to call up the next group of panelists. It says Upledger Institute. I don't think that's a name, I think, but somebody must be representing the Upledger Institute. So if you are here please come. Jerri Fredin, Don Sloma, and Robert Nicoloff will be the first panel. And then we'd also like. Did I skip over somebody?

Male Participant: No.

The Honorable James Gordon: Robert Nicoloff and then Richard Whitten, Andrew John Brunskill, Karl Peterson and Pat Prinz. Okay, so, is there a representative from the Upledger Institute. No, okay.

Jerri Fredin: I'm Jerri Fredin of Seattle and I have been an alternative health care activist since 1980. Excuse me. Today I'm speaking on behalf of a statewide volunteer organization Citizens for Alternative Health Care or CAHC. My testimony focuses on your question how can access to safe and effective CAM practices and interventions be improved. Currently the number one barrier to CAM practices in Washington is the law that grants supreme authority to our state's medical disciplinary board with no provisions for checks and balances. Therefore, to improve access to safe and effective CAM practices we must change that law. Many of us in CAHC know conventional physicians who would like to include CAM in their practices but they dare not for fear of losing their licenses.

While Washington has state laws that permit judicial courts to overrule decisions by other state commissions statutes governing the medical disciplinary board, medical quality assurance commission make it an exception. For this reason CAHC, with the guidance of a state Senator has proposed five amendments to the laws currently governing our medical disciplinary board. One of those five, a checks and balances amendment stems from the Board's 1996 revocation of the medical license of CAM oncologist, Dr. Glen Warner. When Dr. Warner appealed to the King County Superior Court for a reversal of the board's decision revoking his license, a decision I would like to add was made by just three board members who were neither oncologists nor CAM practitioners. The Superior Court Judge, who handled the appeal, informed Dr. Warner that even though he considered the Board's decision wrong he could not overrule it. Later, following an appeal to our former governor, Dr. Warner was likewise advised the state's chief executive did not have the authority to intervene.

However, the governor's legal counsel acknowledged that license revocation requirements do need to be changed in this state. Our proposed checks and balances amendment would give courts the authority to either affirm or overrule contested medical quality assurance commission decisions--an amendment that I would like to emphasize can benefit both CAM and conventional physicians. Draft copies of all five of CAHC's proposed amendments have been submitted to your commission and we seek your support in our endeavor. And I would like to thank you.

The Honorable James Gordon: Thank you very much. Don Sloma.

Don Sloma: Welcome to the northwest and thank you for the opportunity to talk with you about CAM in Washington. I don't speak today for my current employer, the Washington State Board of Health, but rather for one of my former employers, the State Senate Health and Long Term Care Committee. When I was working with that committee in the state Senate for over a period of ten years I had a hand in crafting and modifying lots of the legislation that you've been talking about. And most specifically a bill in 1993 called the Health Services Act that created the Any Category of Provider Law and also the Health Personnel Resources plan. Subsequently, I was involved in the Direct Access to Women's Health Care legislation that was discussed just a moment ago and other pieces. Also earlier in my career I spent time looking under sunset review in our state legislature at acupuncture, midwifery, chiropractic care and others in advising the legislature about those things. I was asked to come today to talk with you about how these laws got on the books. And in particular I want to focus on the Any Category of Provider Law and the law that had to do with Health Personnel Resources Plan.

The long and the short of my comments here really are that those laws depended upon an already established climate of acceptance for alternative medicine here in Washington that stretched back at least into the 1970s. And that was fairly thoroughly examined as a matter of public policy during the 1980s. So that when we came in 1993 to creating what was a sort of public private partnership, if you will, called health reform which in fact actually lasted here for a year or two on the books. The question became not so much should we create a policy for CAM but rather should CAM be included or excluded in a scheme that would regulate and extend access to health care interventions to all citizens in Washington. And the answer to that question [inaudible] climate and the political activism of the CAM community here was, yes it should be included or at least it shouldn't be excluded. And so for that reason, the Any Category of Provider law was included in the Health Services Act in '93.

The Health Personnel Resources Plan followed on that and essentially said, let's make sure we have an adequate supply of these providers and do what's necessary to plan for that. So that's the, the thrust of my comments. And I'd be happy to answer any questions you might have about any of those other statutes.

The Honorable James Gordon: Great, thank you very much. Robert Nicoloff.

Robert Nicoloff, WA State Department of Health: Hi.

The Honorable James Gordon: Hi.

Robert Nicoloff: I'm Bob Nicoloff, Executive Director of the Health Professions Division with the state of Washington Department of Health. I have two brief information documents I would like to share with the commission. The state of, the State Department of Health, among its varied functions and activities, oversees licensure and regulation of over forty health professions. The first document summarizes the five complementary and alternative professions that are regulated, administered by the department. For each profession we include a list of the year the profession first became regulated in our state, the statutory scope of practice of each profession and the current number of licensees in each profession. This is for your information.

As you've heard throughout the day, Washington State has a long tradition and heritage in the utilization of alternative therapies and this is borne out in the history of regulation as well. Of particular note are several professions, which have been recognized and licensed for over eighty years going back before the twenties. The second document highlights the consumer protection education activities of our agency. Consumers at this point can call twenty four hours a day on an automated line to obtain basic licensure information on any provider including alternative providers they are considering using. This includes information on the length of time the licensee has practiced in the state, as well as information regarding concerns that might have been received concerning the practitioner. And this also outlines our disciplinary and complaint investigation process for your information. Also, numerically we've received over a half a million inquiries and verifications of licensure during the 1997-1999 period. So this information is being requested and utilized.

And in terms of the disciplinary data, in closing, it shows that the alternative and complementary approaches professions generally have about the same number of complaints as other professions and in some cases there's some of these professions they actually have less than the other health professions that we regulate. I'd like to thank the commission for this opportunity and I'd be happy to answer any questions.

The Honorable James Gordon: Thank you very much. Richard Whitten.

Richard Whitten, MD, Washington Health Care Authority: Thank you. I'm Dick Whitten, I'm a general internist. I've been for ten years the Medical Director of Washington's Health Care Authority. Our Health Care Authority administers three different care programs for our public employees in the state, for our basic health plan--which is a plan focused on the working poor, those under two hundred percent of federal poverty level, not eligible for Medicaid, and our community health services--our community clinic program. We provide access to our contracts to about half a million enrollees. Health Care Authority also overviews the Uniform Medical Plan which is a state administered self insured provider, a preferred provider organization and Dr. Brunskill's here from that prospective and will provide some comments after mine.

I was asked to help provide a prospective on what we've learned, what we think we've learned in the past dozen years from the Health Care Authority viewpoint in administering and restructuring state health programs that might help you. We think we have three suggestions. They are to eliminate arbitrary exclusions, to avoid mandates and to structure benefits in such a way that they focus on outcomes in a scientific basis. And I'll comment on each of these three.

The first was to eliminate arbitrary exclusions. Each of our programs historically had some exclusions. You've seen lots of them. They're real common for CAM to see something specifically excluded. Now let me give you an example. Basic Health since it's inception in 1988 excluded chiropractic. However a little short time after that the Agency for Health Care Policy and Research, now the Agency for Research and Quality came out with a study that showed allopathic physicians were not very good at treating either acute or chronic pain. By removing the exclusion for chiropractic in Washington's Basic Health Plan we made it possible and encouraged our health plans to work with individual providers and provider groups to seek better outcomes, eliminating an arbitrary exclusion.

The second recommendation was to avoid mandates. This may be less popular here, but we believe that where legislation or a regulatory body or a purchaser mandates a specific coverage we create an entitlement. When we create an entitlement we get both the good and the less useful. After having established such an entitlement it's very hard to get anybody to focus on optimizing or again regain any focus on improving efficacy and cost effectiveness. An example, our Basic Health Plan once had a specific exclusion for out patient supplies and equipment. By removing this and instead putting in words where the use of the services, supplies or equipment is expected to result in a lower total out of pocket to the plans if the enrollee stays present for four years. We turn the focus around and try to get emphasis on what's cost effective, avoid a specific mandate.

Thirdly, to structure the benefits such that they focus on outcomes in a scientific basis. Our plan, Basic Health is one example, like many others had a specific exclusion for experimental/investigational. This is a national topic now. Rather than just finding a way to mandate this, we put in certain coverage criteria which established the services required because of a disease, illness or injury performed for the primary purpose of preventing, improving or stabilizing the disease, illness or injury. There is sufficient evidence to indicate that the service will directly improve the length or quality of life. The service's expected beneficial effects on the length or quality of life out ways its expected harmful effects. And fourth, the service is a cost-effective method available to address the disease, illness or injury. Such criteria are equally friendly to all types of efficacious care including CAM. We believe the three guidelines to eliminate arbitrary exclusions, to avoid mandates and to structure benefits such that they focus on outcomes on a scientific basis will help you and has continued to help us.

The Honorable James Gordon: Great, thank you very much. I'm sure, at least, I'll want to come back to that. I want to hear more about it. Andrew Brunskill.

Andrew John Brunskill, MD, Uniform Medical Plan, Health Care Authority: Welcome to the northwest. I'm the Medical Director for a self finance, non-profit health plan for state employees here in Washington, the Uniform Medical Plan. But I am representing myself not the agency in this statement. There is a strong movement to encourage plans to support evidence based, cost sensitive care. But in reality there are a lot of pinnacle practices being undertaken by both CAM and non CAM providers whose evidence base is poor or do not appear to be cost sensitive. Examples include injections with placental extracts, nutritional counseling, massage therapy, or on the other hand stem cell transplants, pet scan imaging and newly produced medications. The situation is exacerbated by different patterns of billing practices by different providers.

I'd like, happy to give examples of why it can be helpful for plans to be able to refer to federal materials on what treatments should be supported and what the present evidence on cost and effectiveness is for these treatments. Consistent support for federal agencies, like the U.S. Preventive Services Task Force Guidelines or for the Agency for Health Care Research and Quality, can provide useful and accountable resources which, as long as CAM advocates are represented, can provide a well documented and reasoned basis for our health plan coverage decisions.

The Honorable James Gordon: Thank you. Let's begin Tom at your end. Any questions?

The Honorable Tom Chappell: Well I hate to keep asking this question but I will. Mr. Sloma how does, what are the key strategies of political activism that result in success of licensing in a state where CAM practitioners? You mentioned, I, your story was political activism is what resulted in a change in the law to include CAM practitioners. What are the? [cross-talking]

Don Sloma: I would say, yes.

The Honorable Tom Chappell: I'm not a politician. I'd just like to know how it works.

Don Sloma: Well, if I knew that, we'd still have a Health Services Act sir.

The Honorable Tom Chappell: However, you were there [inaudible].

Don Sloma: I think really it was a combination of citizen effort and the health professions organized and bringing those issues forward in the political environment. But I would also say that our state, and you can see Dr. Whitten on the panel with me today, enjoys a, I think uncharacteristically progressive medical communities sort of leadership. And I think some of those bridges being built across professions before anyone comes politically to the legislature means that the very considerable influence of the medical association was not brought fully to bear to kill some of this legislation over the years and it could have been. When Medical Directors, like Dr. Whitten and others, who have been served in state government come forward and say, we're not sure that there isn't something here. It isn't a ringing endorsement. But sometimes all that's necessary is for powerful people to take a step back in order to let something happen in the political process. So I'd say that sort of combination.

The Honorable Tom Chappell: Thank you.

Female Participant: Yes to Dr. Whitten. I noticed your reference to chiropractic being included because they were deemed to be effective for neck and low back pain. And I can only speak from my professional prospective, which was, that means that chiropractors were not allowed to participate based on their practice act. And I'm wonder in the Health Care Authority as they integrate other health care professionals will they be allowed to participate based on their practice act or will some other group decide the scope of their practice within the Authority?

Richard Whitten, MD: We've worked hard to remove any practitioner specific items in any of the contracts we've written. As I tried to give, chiropractor was an example to specifically remove anything that limited practice by a specific category provider. The practice, the extent of practice is completely governed by the individual board. So that's not something that comes under the Health Care Authority. We're a contractor for the, for the provision of services. We are trying to structure things in such a way that the health plans will look for evidence and for, and making arrangements within the limitations of the Practice Act. We all must be governed by that within our state. But try to look for evidence bases of which types of procedures and activities are most useful.

Just to build on what Mr. Sloma said a second ago the AHCPR study was based here. Dr. Rick Dayo, Group Health and others helped show us that there were some really much better ways of taking care of back pain than taking people who didn't need it and giving them surgery. So and there's a lot of physicians that are really interested in trying to find what's a better way to treat people.

The Honorable Effie Poy Yew Chow: We have a group of very impressive kind of history on influence of our health care here in Washington. And thank you for all your efforts. I have a generic question. We talk about CAM and integrating CAM and CAM practitioners, non CAM practitioners. Do you have a definition of what CAM is? We, you know, I myself, it is like we haven't really described. It's like everything outside of the modern western medicine. Is that what you take, or do you have a more definitive definition?

Male Participant: I'll be honest with you, we use the CAM terms these days because that's the term everyone else uses. During the years we were doing this it was about what's the care, people with Asian and Pacific Island background want. What's the care that people who've grown up in and around the northwest want? What's some of the traditional medicine that people who live in this country, who've been here for thousands of years want and use? Is there any value there. Does it improve people's health status? And it came up as naturopathy. It came up as acupuncture. Only in the last number of years after much of the work was done and much of the research was done here in Washington did the term CAM come to prominence and be sort of talked about. So I'll take the definition that that you want to take. What we're interested in I think and what, I should add to that question that was asked earlier.

One thing that helped in Washington was people in Washington politics have kept a bit of an eye on the ball in terms of looking at health status improvement. The fact that these treatments are, have been demonstrated to be safe, and effective and inexpensive recommends them highly to policy makers in Washington. The only thing that's stronger than biomedicine perhaps in America is pragmatism.

Jerri Fredin: The written testimony that I've handed in here on our five amendments, we came up with what we thought was about the simplest way of [inaudible].

The Honorable James Gordon: Could you speak closer to the mic please?

Jerri Fredin: Excuse me can, is that better? In the written testimony that I have handed in on five amendments that we're going to be proposing we had included what we hoped was a rather simple definition of CAM. Integrative or complementary health care also known as complementary or complementary and alternative medicine (CAM) shall mean those health care methods of diagnosis, treatment or interventions that may depart from conventional health care and the conventional standard of care.

The Honorable James Gordon: Thank you. Linnea.

The Honorable Linnea Larson: Yes, this is directed to Dr. Whitten. I very much appreciate all of your pretty formidable work and your brevity in your recommendations and therefore I would actually like you to submit any kind of what you said to us cause I cannot really remember it. You know the examples that you used to illustrate avoiding mandates and eliminating arbitrary exclusion.

Male Participant: For Mr. Nicoloff. A question about the scope of practice.

Mr. Robert Nicoloff: Yes.

Male Participant: Thank you for providing that to us. I was reading the naturopathic physician scope of practice, which I observed was first licensed in 1919 and I'm just wondering if it's time for a change. There's some, there's some sort of oxymoronic pieces in here. They are excluded from treating malignancies or neoplastic diseases. Now I can understand perhaps chemotherapy would be excluded. But what about ancillary care, palliative modalities for someone who has cancer? Would that person be disciplined by the board? The second question where I'm taking for an expansion of scope. Here I'm looking for maybe, maybe a sort of constriction in scope. Radiography, they're allowed to order but they can't interpret an x-ray. So as an internist, I have a hard time ordering tests that I don't understand and I can't interpret. So what's the range of the scope and has anyone looked at the?

Robert Nicoloff: I might note that in 1919 it was really a predecessor profession. It was called drugless therapy and really this law was rewritten. I think Dr. Labriola talked earlier today and in the mid-eighties this was written. I know there's a proposal in our legislature to update the scope of practice and I think it addresses several areas that you mentioned but. But obviously in each case, we will look at the specifics with the consultation of our naturopathic advisory committee and identify you know, do the specifics apply within the scope? And was it reasonable given, and obviously in any of this language there's some interpretation.

Male Participant: Could you supply us with the bill even though I understand it, you know, it hasn't passed.

Robert Nicoloff: We will and I think the association, Naturopathic Association will as well.

Male Participant: Thank you.

Robert Nicoloff: And I also have full copies of the, of the laws I can leave.

Male Participant: Great, thank you.

Male Participant: Dr. Whitten, I have a question. The three principles are very clearly articulated. Can you give us a sense of how, how this works in practice. If you're guided by eliminating arbitrary exclusions, etc. what does this mean for the people of Washington? What does this mean for the statutes? And what does it mean for the people of Washington in terms of what kind of health care they can look to and how does it affect coverage and all those things?

Richard Whitten: It's a big question. Two cautions, it, it, it needs to take place over time and it doesn't take place the same. You asked a question a minute ago can you define CAM. Well obviously you have many different things here together. We've attempted to identify in specific areas where there is good evidence. These would be things that would be good substitutes or changes from what we now have in our benefits packages. We've made those changes. This has taken place over about eight or nine years. So these aren't something, it would be very difficult to eliminate exclusions and not have, do all these things at once because of the dramatic impact on utilization. But taking some time with, and others have pushed you in which you're helping us do, to identify good sources of data to be able to identify what are cost effective useful alternatives. No only to, things were currently [inaudible], but also to change some of the things we're currently doing. I think that would, that's what we have done with some of the ones I've outlined.

Male Participant: But can you give me a sense of what this might mean practically for someone?

Richard Whitten: Well, sure. We have, for instance, within our contracts with the state Health Care Authority over the last several years. We now have Naturopathic physicians with some of our plans that are primary care providers. We have chiropractors who are part of the provider network with a number of our health plans providing care in concert with some of the others. Now they don't all have this and in some places we certainly don't have what many people in this audience would like to have. But it has enable and encouraged this to take place over time. First remove the exclusion and try to help identify and motivate changes in this direction.

Male Participant: And this is health contracts for?

Richard Whitten: The State Health Care Authority has contracts for the, as I mentioned, the public employees for our basic health plan and we also help with the contracting. And we coordinate with our Department of Social and Health Services Medical Assistance Administration contracts.

Male Participant: Could you give a, and those, so state employees then sign up for a particular plan that you offer?

Richard Whitten: Yes sir, that's correct.

Male Participant: And your plans would include these five groups that Mr. Nicoloff's told us about or not necessarily?

Richard Whitten: Some of our plans would have a variety of the different providers. I'd have to, I could certainly get an answer for that. And we've certainly seen a change over the last few years. But I'm not sure which. I know some of them do.

Male Participant: I think what will be helpful and obviously there is not time for it now is to give us, give us those plans and if you would and I know this is, again, you're very far out ahead of most if not all of the country. So it would be very helpful if you would give us the plans and the rationale for each plan and some sense of what that would mean in terms of what an employee would pay and what an employee could expect.

Richard Whitten: We can try. May I encourage you, you have several people providing testimony to you or on the formative committee who represents some of the health plans and they may be able to answer the reasons, the motivations better than I can. But we will try to do what you're asking.

Male Participant: It would be extremely helpful because we're in a position to be able to make national recommendations and perhaps recommendations for federal employees. So the data that you have here is really, you know, and what you've learned, the lessons you've learned in these eight or nine years. Anything that you could sort of, I'm not asking you to write a Ph.D. thesis on it but, anything that you could take out, lessons you've learned and specific suggestions you would give us and why you would give us those suggestions would be very helpful.

Male Participant: I'm sure you don't have enough else to do but.

Male Participant: Jim, one more question please. Dr. Whitten, your third criterion on structuring the incentives on scientific outcomes -- just, help me understand where the promotion of wellness fits within that idea. For instance let's just think about regular cleaning of teeth. It's not a disease. It's a preventative measure. To what extent does this criterion embrace promotion of wellness or prevention?

Robert Whitten: There are several parts to that question. The perception of how much benefit it has may be different from what others might think. Just to pick the example you have. Not many of us relish going to the dentist. But there are few things shown that have better proven preventive benefit than prophylactic dental services for children. So you would try to look at and weigh that benefit what way. If you were to just base it on a survey of children and how happy they were to get their teeth cleaned you would come up with a different conclusion than if you. So I'm, and that's a problem when we try to look at who is making a judgment on whose behalf.

On the other hand, we're now making many more, doing many more surveys of people satisfaction with the care they're receiving in addition to their return to work, they return to function. As we begin to get some further objective measures I think a lot of those will play a role in our ability to assess the outcomes of various alternatives in care. Am I answering your question? I'm trying to.

Male Participant: No, that's helpful. And I guess I, I'm also aware that the real efficacy is in consistency of the consumer to keep coming back for the same preventative practice because he or she decides that it's very efficacious and then there's market and now there's thirty billion dollars of a market and, you know, that's a measure. The measurability can be in the consumer's consistency to keep coming back for the same practice.

Male Participant: Consumers and plans and we as purchasers are all influenced by things such as Dr. Brunskill mentioned. When we have something like AHRQ that helps identify what our effective prophylactic benefits. It helps get us all on that page. We need a lot more research along those lines.

The Honorable James Gordon: Thank you very much. We'll be back in touch. We look forward to hearing from you as well. Earlier I called Karl Peterson and Pat Prinz. Is either one of you here? Okay. Kay Lahdenpera, Jane Nelson, Sheila Rhodes, Vera Ridderbusch, Katherine Schmidt and Ronald Schneeweiss. Okay. Then we'll begin with the three of you who are here. We thank you for being with us through this long day. And let's begin. Kay Lahdenpera.

Kay Lahdenpera: Well I bring you greetings from Alaska. I'm from Anchorage and I wanted to tell you that I'm recently retired and my efforts will be in the area of public health and a public health nurse manager. I've also had my MPH. I feel strongly in a few areas here. One would be in the area of research. I feel that it's terribly necessary for CAM to be recognized within the western medicine research that I realize a CDC and some of the other areas have perhaps specific criteria for their research. But I would hope that we have the finders from both sides--conventional and CAM--coming to the table with open minds to gain an understanding and appreciate both types of research. Until we can reach that level we will probably have some problems.

We need to establish a common ground that both can agree upon to further expand the research of CAM. And I can tell you that CAM is alive and well in Alaska. I recently attended the Alaska State Nurses Association. We had a very exciting track on alternative health care. And then I also attended, and this has been this past month, and I've also attended the Alaska State Nurse Practitioner Program. I am not a nurse practitioner. I did receive a recent award from, a national award as an advocate and I do feel strongly that we have a lot of clinics in Alaska, physicians and nurse practitioner run. And the nurses and the nurse practitioners were extremely interested in CAM. So I feel strongly about training education certification and licensure. And until we can have this agreement, depending on the scope of practice, we need to have in addition to specialized institutions of current CAM learning, like here in the Pacific Northwest, the Bastyr University, we need to have CAM curriculum should be available in traditional universities, such as schools of medicine which I know there are many. But we need to expand that into schools of nursing, schools of pharmacy, schools of dentistry, schools of public health and schools of veterinarian and I'm sure [inaudible]. But we need to have this and there's a request among professionals in this area. And we need to have, I feel that it can be done. But it needs to be done with leaders in the different disciplines in CAM working with traditional leaders.

May I finish my sentence? Thank you. Traditional leaders in the, traditional medicine as well as teams of faculty from the various universities, health care professional schools to standardize, long sentence, the necessary required [inaudible] to each school's scope of practice to include CAM education and services. This would be an additional basic component to existing curriculum. And the University of Alaska, Anchorage School of Nursing would love to have a CAM component but money is the issue.

The Honorable James Gordon: Okay, thank you. Jane Nelson.

Jane Bernice Nelson, MA, North Bend Elementary: Hi.

The Honorable James Gordon: Hi.

Jane Bernice Nelson: I'm speaking regarding the guidance for access to delivery of and reimbursement for complementary and alternative medicine practices and interventions. I'm here today as just an ordinary person, a school teacher to testify to the fact that if it weren't for CAM, complementary and alternative medicine, I would still be confined to a wheelchair that I had been in for over ten years. Although I had the mechanical ability to walk I was not able to walk even across a room because of a lingering sports injury from tendonitis in both legs and ankles. And after several years of physical therapy doctors and physical therapists had given up on my condition. It took only sixteen treatments of complementary and a combined alternative medicine, including Chi Gung treatments, acupuncture and Chinese herbs to get me up walking without pain, no longer needing the wheelchair and therapy, thus stopping the continual cycle of injury re-injury. So I'm here today before you to sing the praises of CAM. And my vision is that these procedures would be covered by medical health coverage so that ordinary people just like myself who really need these beneficial treatments don't have to spend their life savings in order to get the treatment they need.

Recently, I attended a health benefits fair for teachers and realized as you were commenting previously that in the state of Washington, more and more health care providers are now beginning to cover some form of acupuncture treatments on insurance, such as the one I have, Premiere Blue Cross and Group Health. Large health insurance companies like Group Health are now providing specific coverage for complementary and alternative healing treatments. I read the brochure and read a list off of acupuncture, acupressure, yoga and Tae Chi. I would hope that medical Chi Gung and Chinese herbs could be added to this list as very beneficial forms of complementary and alternative medicine. And I hope that in the future both will be covered by insurance. Thank you very much.

The Honorable James Gordon: Thank you. The next speaker, I have to preface it by saying I, she gave me a lift to the airport in Bellingham at five o'clock in the morning and was telling me about her work. And I said will you come down here so I really appreciate your coming Sheila. Sheila Rhodes.

Sheila Kennedy Rhodes, Mt. Baker Care Center: That's to tell you that I am the country mouse in the city. I am from a community a hundred miles to the north, twenty miles from the Canadian border. This reality that was presented to you today is not mine. But it is the second most exciting day I have spent in the last month because you and everyone who's spoken today brings us so much hope.

In my community, I want to tell you the rest of the story after Dr. Gordon came. I had the privilege of helping our medical society, the Executive Committee, bring Dr. Gordon to speak to our community about integrated medicine, to introduce the concept. He can tell you how well received it was. It was very exciting. The rest of the story is I saw my primary care practitioner in the medical society meeting that night. So I trotted in two weeks later and asked him how he received the information. And he said it was very persuasive. He would use it if he knew how, but I needed to address for him how in the managed care climate when he must spend no more than an average of ten minutes per patient per day. He must see thirty patients a day in order to break even, quote. But he would have time and the leisure to listen and work truly collaboratively with his patients. He wants to do that, he's frustrated by not being able to do it but sees no other way to feed his family. And he used those terms.

The second part of the rest of the story is as we were discussing this in a patient treatment room there was a knock on the door. He opened the door and a pharmaceutical representative was on the other side of the door and he said, I'll be with you in a minute Jim. He finished his conversation with me and he walked out and I heard him say. What have you got for me today Jim in your Pandora's box? I was going to tell you about Trudy who is my patient. I work in a long-term care facility, I'm Director of Social Services. Trudy is on twenty-nine different medications. It takes her ten minutes morning and evening and three quarters of a cup of applesauce to get that stuff down. She's not hungry for breakfast afterwards. And she's not hungry for dinner. In a way I am talking about Trudy because I see and work with the vulnerable population enthrall to conventional medicine and the pharmaceutical industry.

My recommendations are: 1) That you investigate the perception by primary care providers that they must devote so little time to every patient in order to meet expenses and 2) endeavor to bring into balance the enormous influence that pharmaceutical has on our conventional medical practitioners. Thank you.

The Honorable James Gordon: Thank you very much. I would like you to, take the chair's privilege, to just say a few words in addition to what you just said that was so powerful about your sense of the utility of CAM and of another approach in working with older people in nursing homes and long term care facilities, if you would.

Sheila Rhodes: I can give you a specific example. I come from an advocacy background. I joined the long term care industry, changed careers three years ago. Early in my career as Director of Social Services, I didn't know about all the rules and regulations that govern long term care. And one of the major concerns in every nursing home is strong urine smell. And you want a smell free environment. Well the way it was handled was with a chemical spray that caused an allergic reaction with some of our staff members and patients and diligence on the part of the aids. I went down to our local herbal specialist and said, this is our problem what can you recommend? And she came up with a what we call the SFPT, he smell free PT. And I was able to smuggle it into our nursing home as a food because the three items that are in that tea are so well known and trusted that it did not arouse the concerns of our medical practitioners.

However, on the strength of that success, and by the way we are a smell free environment, I, then the nurses approached me and said, what can you do about chronic UTIs, urinary tract infections? This is a terrible problem among our elderly. And in fact there was one lady that I had admitted who had had so many that her doctor had just prescribed life time antibiotics for the remainder of her life. This was three years ago. So I trotted back down to the herbalist and I said, what have you got for this? And she did some research, came up with a tea that has a number of different elements in it, some of them more esoteric. I presented that to the physician and the physician said absolutely not, unless you can show me how it interacts with her other medications. I sent him what I could find from medical journals and a reference book like our PDR from Britain. His response was until I see you U.S. evidence based information absolutely not. However, this lady now has been on antibiotics for three years. Since she was put on antibiotics six more medications were added because of side effects of lifetime antibiotics.

Another patient that we have, a long term care patient who is forty four years old suffering from an aggressive form of MS elected to try this tea because she too was averaging a UTI every six weeks. She has not had a UTI in two years and one month and she drinks a cup of that tea every morning.

The Honorable James Gordon: Thank you very much. Tom would you like to begin? While you're waiting if you're waiting, Ming definitely has a question.

The Honorable Xiaoming Tian: Okay, the question regarding, Ms. Nelson, and the regarding, you mentioned that you want to add medical Chi Gung into CAM. Why you use medical Chi Gung? What is definition of medical Chi Gung?

Jane Bernice Nelson: Oh, healing form of Chi Gung as opposed to a Marshall Art form.

The Honorable Xiaoming Tian: So the Chi Gung and medical Chi Gung you think no definition the same, because there is association in the [inaudible] association of medical Chi Gung? Because using the medical Chi Gung either using external Chi or teach patient to treat patient has to be treated the condition not only for prevention. So I think you mention very interesting in a definition. Thank you.

The Honorable James Gordon: Tom, want to start?

The Honorable Tom Chappell: Well, thank you. Mrs. Rhodes? I'm curious and I don't mean this to be a crass question but is the economic survivability of your primary physician essential to you or is the access to the care that you need sufficient?

Sheila Kennedy Rhodes: Guess who changed doctors October 15?

Female Participant: It also is sad that, you know, for like patients with chronic urinary tract infections that you know the United States pharmacopoegists reviewed the evidence on cranberry and the studies in elder patients actually in long term care facilities and looking at the overwhelming evidence that it reduces bacteria and pyrexia in female older women with chronic recurrent UTIs. This may, there, what I guess my point is, there are, there is more research that is becoming available and it is U.S. based. And I think a lot of our work and part of what our commission will address is, how do you get that information to busy practitioners so that, you know, that that perhaps he or she could have said to you well I feel uncomfortable with those herbs. Because we don't know a lot about them and she's on a lot of drugs which. is also a valid concern. But we maybe could try her on cranberry concentrate either in pills or in juice. So I applaud you for your work, especially with people in these long term care facilities. And also ask that you be hopeful because there is more U.S. research that is becoming available and hopefully we can get that information out so that, so that all people benefit from their care.

One other thing is that a lot of physicians, we have moved from seeing the ten minute patients. But it also has meant that you live on thirty thousand dollars a year instead of ninety thousand. But it's a matter of physicians deciding how much you need to live on.

Sheila Kennedy Rhodes: That's correct. There seems to be a snowball effect in order to meet their perceived demands of managed care they've had to in my, as a particular doctor now has a seven day a week practice. And he has hired enormous numbers of people to manage the paperwork. So he has to see more patients to pay the people. [inaudible] is beautiful. We do offer cranberry. And in that particular patient who is on three yeas of antibiotics thus far, age ninety one. She does also have prescribed chlorophyll tablets and cranberry.

Female Participant: And she still is on the antibiotics?

Sheila Kennedy Rhodes: Yes.

Female Participant: Thank you very much for your presentations. Jane, you're a teacher and you experienced this, this recovery. We haven't had many teachers on our panel if any at all. And I wonder if you would say anything about your impression in how CAM could help with the teaching profession or the students or whatever.

Jane Bernice Nelson: Well, part of my recovery also includes continuing to do the exercises and so there is an active, you know, part that I play too to keep that going, my health going. And I've also in the last year done some things with my students to do some, some of the certain exercises. And some teachers use some of the Chi Gung practices for reducing stress and exercise also from a stressful job.

The Honorable James Gordon: Thank you. I want to thank all three of you and thank, thank all of us. One thing that, one of the reasons why I particularly wanted Sheila to come, and this is really speaking to the commissioners, is I really think it's important that we address more some of the problems of the elderly and particularly institutionalized elderly. So I hope that we'll do that in subsequent sessions. I was so struck by her example. Also what she did is I was giving a talk up there to the community and there must have been, you must have had a hundred and fifty people over seventy five elderly people who were there aside from everybody else in the community. So it was really extraordinary. Joe.

The Honorable Joseph Fins: I do have a, Jim's comment provoked a a question. There is a in the NCI a best case sort of methodology where practitioners who find something that might help malignancies can write in and access people at the NCI to to cultivate the story so we can generate, they can generate a hypothesis that can then be tested. What kind of services would be helpful to you in a long term care facility that the government could provide, a comparable thing for say geriatric medicine to help you interact so that some scientist at the NIH could develop a hypothesis that could then be tested? I mean, what, what kind of resources would you need to sort of write up these cases and what you shared with us today so that it could be studied further?

Sheila Kennedy Rhodes: I would have no trouble writing up the cases. I would need to know where to send them.

The Honorable Joseph Fins: And how would you get that message out to you know, your colleagues?

Sheila Kennedy Rhodes: Same way I got all those old people to come and hear Dr. Gordon.

The Honorable Joseph Fins: All right, maybe we should.

Male Participant: I think one of the things that we need to address too is how do, how do we encourage the various institutes at NIH as well as the sort of public agencies to sponsor demonstration projects and to really encourage people who--

[End of tape.]