Archive
WHITE HOUSE COMMISSION
on
COMPLEMENTARY and ALTERNATIVE MEDICINE POLICY
MEETING ON THE ACCESS AND DELIVERY OF
COMPLEMENTARY AND ALTERNATIVE MEDICINE SERVICES
+ + +
Volume II
+ + +
Tuesday, December 5, 2000
8:00 a.m.
(Morning Session)
Hubert H. Humphrey Building, Room 800
200 Independence Avenue, SW
Washington, D.C.
PARTICIPANTS:
Chairperson:
James S. Gordon, M.D., Director
The Center for Mind-Body Medicine
Commission Members:
George M. Bernier, Jr., M.D.
Vice President for Education
University of Texas Medical Branch
David Bresler, Ph.D., LAc, OME
Dipl.Ac.(NCCAOM)
Founder and Executive Director
The Bresler Center, Inc.
Thomas Chappell
Co-Founder and President
Tom's of Maine, Inc.
Effie Poy Yew Chow, Ph.D., R.N., DiplAc (NCCA)
Qigong Grandmaster
President, East-West Academy of Healing Arts
George T. DeVries, III
Chairman, CEO of American Specialty Health
William R. Fair, M.D.
Attending Surgeon, Urology (Emeritus)
Memorial Sloan-Kettering Cancer Center
Chairman, Clinical Advisory Board of Health, LLC
Joseph J. Fins, M.D., F.A.C.P.
Associate Professor of Medicine
Weill Medical College of Cornell University
Director of Medical Ethics
New York Presbyterian Hospital-Cornell Campus
Veronica Gutierrez, D.C.
Gutierrez Family Chiropractic
PARTICIPANTS (continued):
Wayne B. Jonas, M.D.
Department of Family Medicine
Uniformed Services University of the Health Sciences
Charlotte Kerr, R.S.M.
Traditional Acupuncture Institute, Inc.
Linnea Signe Larson, LCSW, LMFT
Associate Director
West Suburban Health Care
Center for Integrative Medicine
Tieraona Low Dog, M.D., A.H.G.
(Private Practice)
Conchita M. Paz, M.D.
(Private Practice)
Buford L. Rolin
Poarch Band of Creek Indians
Julia R. Scott
President
National Black Women's Health Project
Xiao Ming Tian, M.D., LAc
Director, Wildwood Acupuncture Center
Director, Academy of Acupuncture &
Chinese Medicine
Wildwood Medical Center
Donald W. Warren, D.D.S.
Diplomate of the American Board of
Head, Neck & Facial Pain
Commission Members Not Present:
Dean Ornish, M.D.
President/Director
Preventative Medicine Research Institute
Clinical Professor of Medicine
University of California, San Francisco
PARTICIPANTS (continued):
Executive Staff:
Stephen C. Groft, Pharm.D.
Executive Director
Michele M. Chang, C.M.F., M.P.H.
Executive Secretary
Doris A. Kingsbury
Program Assistant
Geraldine B. Pollen, M.A.
Senior Program Analyst
Joseph M. Kaczmarczyk, D.O., M.P.H.
Senior Medical Advisor
C O N T E N T S
Page No.
Session V: Meeting Public Needs/Systems of Delivery
Private Practice
Robert Atkins, MD ................................. 6
Nursing
Charlotte Eliopoulos, RCN, MPH, PhD .............. 12
Stand-Alone CAM Center
Mort Rosenthal, MBA .............................. 16
Panel Discussion ................................... 22
Community Health Clinics
Tom Trompeter, MPA ............................... 54
Hospital-Based Centers
Sylver Quevedo, MD ............................... 60
Academic Centers
Woodson Merrell, MD .............................. 65
Panel Discussion ................................... 70
Managed Care Organizations
James Dillard, MD, DC, CAc ...................... 105
Anna Silberman, MPH ............................. 110
Lori Bielinksi, LMP ............................. 115
Panel Discussion .................................. 121
Ayurveda
Robert Schneider, MD ............................ 143
Naturopathic Medicine
Tori Hudson, ND ................................. 149
Traditional Chinese Medicine
Robert Duggan, MA, MAc .......................... 155
Panel Discussion .................................. 160
Public Comment
Bruce Nordstrom, American Chiropractic
Association ................................... 195
Neal D. Barnard, Physicians Committee
for Responsible Medicine ...................... 198
Doreen Chen, Chinese Medicine Council, AAOM ..... 201
Gary Sandman, Integrative Medicine, LLC ......... 204
Danny Freund, Pennsylvania State University ..... 207
Panel Discussion .................................. 210
Melinna Giannini, Alternative Link .............. 224
Jane Hersey, Feingold Association ............... 226
Boyd Landry, The Coalition for Natural Health ... 229
Lawrence A. Plumlee, National Coalition for
the Chemically Injured ........................ 232
Michael J. Rohrbacher, Certification Board for
Music Therapists, Inc. ........................ 235
Panel Discussion .................................. 239
Andrew L. Rubman, American Association of
Naturopathic Physicians ....................... 249
Marshall H. Sager, American Academy of Medical
Acupuncture ................................... 252
Diana Miller .................................... 255
Courtney Banks .................................. 257
Richard Pavek, Biofield Research Institute ...... 260
Panel Discussion .................................. 263
Session VI: CAM Integration in Existing Delivery Systems
Alan Trachtenberg, MD, MPH
Substance Abuse and Mental Health Administration
(SAMHSA) ...................................... 273
Milton Hammerly, MD
Catholic Health Initiatives ................... 278
Panel Discussion .................................. 282
Session VII: Commissioners' Discussion ............ 304
Adjournment ....................................... 349
P R O C E E D I N G S [8:00 a.m.]
[Moment of silence observed.]
Session V: Meeting Public Needs/Systems of Delivery
MS. CHANG: Good morning, everyone. We are going
to get started, so if the first panelists could please come
to the table. The first panelists are
DR. Robert Atkins and
DR. Charlotte Eliopoulos, and
Mort Rosenthal.
DR. GORDON: Thank you very much. I want to thank
all of you for a long day, a long attentive day yesterday,
and for being here bright and early this morning, ready to
roll. And thank you, too, for coming early this morning,
those of you on the panel.
So we will move down. The panel will begin with
DR. Robert Atkins.
Good morning, Bob.
Session V: Meeting Public Needs/Systems of Delivery
DR. ATKINS: Good morning. We are going to speak
from the vantage point of a doctor who practiced a different
kind of medicine, just with the idea of getting better
outcomes, and this began in 1972 when he got a little
disillusioned with statements made by the American Medical
Association, when they basically said that the work that I
had already observed with the regard to the effect of
changing one's diet was not supported by the scientific
literature.
I would have to tell you that the idea for my diet
came from The AMA Journals, and it was the teaching at the
time, 1963. So I vowed that the best thing that I could do
would be to just try to practice medicine more effectively
than mainstream medicine was doing.
After about 15 years of that, I came to the
conclusion that we had succeeded in many areas in getting
better outcomes certainly than I had gotten when I was
practicing mainstream internal medicine and cardiology. So
I wrote a book and the purpose was to describe the new
medicine. I hit upon the title of "Complementary Medicine,"
and the book was called "
DR. Atkins' Health Revolution: How
Complementary Medicine Can Extend Your Life."
The reason I say this is because I do believe that
the term complementary medicine very much applies to a
practicing physician and is, in fact, what I think should be
the future of mainstream medication, because if we define
complementary medicine as I have defined it, and the way my
colleagues and the groups that I belong to, the Foundation
for the Advancement of Innovative Medicine, AKM, and so on,
it is not that we are adding complementary therapies to
mainstream medicine, but rather it is an entire system of
patient care, a different system, a system which is based on
a working knowledge of all of the healing arts.
I say "working knowledge" because I think when we
make our decisions, we select therapies from all of the
healing arts based primarily on the highest benefit-to-risk
ratios and on their ability to synergize with other
therapies.
Now it turns out that when we use the benefit-to-
risk ratio, you end up using an awful lot of nontoxic
nutritional therapies and a lot less of the pharmaceuticals,
mainly because of the risk involved with pharmaceuticals.
It incorporates mainstream thinking, though it
incorporates mainstream thinking when it applies, but not
when it excludes, safe and alternative therapies. It
recognizes the multifaceted aspects of illness and expects
all aspects to be considered in patient care. The term
holistic really applies here.
It feels that in enhancing the host's resistance
to illness is often more important than destroying the
illness itself. The most striking example of that is in
cancer therapy, where host resistance or host strengthening
is not a part of mainstream teaching. Its therapies, which
are very often nutritional, work synergistically, and
optimal results will not be achieved with single therapies.
I say all of this became complementary medicine's
effectiveness needs to be proven, and for many reasons, it
is the lack of proof and the need for proof which is at the
top of the list of things that would have to be done. In
order to convince the other practitioners of mainstream
medicine that they should expand their horizons to include
alternatives, to include safe, nontoxic alternatives, and
consider them perhaps as better alternatives than
pharmaceuticals and surgery.
The first order of business is to have it proven
that it works, and that it gets better outcomes, at least
equivalent outcomes, or that it helps cut down the cost of
medical care, which is another important point, but in some
way, something has to be proven.
Now, complementary medicine offers the government
an opportunity to solve its most pressing health problem,
and how best to solve the problem of increasing health care
costs. The American Ministry of Medicine has been allowed
to develop protocols involving optional surgery, described
as mandatory. People are not told that their heart
blockages are reversible, is a perfect example, or expense,
risky therapies that are given unnecessarily, such as giving
adjutant cancer therapy to people when the surgeon has
already removed the cancer, and also the use of drugs with
side effects when vita-nutrients can do the same job.
The result is the U.S. has the greatest per capita
health care expenses in the world. Complementary medicine,
by providing inexpensive, nutritional and non-surgical
options, can go a long way towards cutting these expenses,
and if the results that I have gotten, and my associates and
the organizations that I belong to hold up to scrutiny, the
number of hospital stays will plummet dramatically and,
therefore, I think we can do some research that I think will
point in these directions.
Thank you.
DR. GORDON: Thank you very much, Bob.
One of the things, before we move on to
DR. Eliopoulos, that I want to say to remind the Commissioners
of, and also inform all of you about, is that these panels,
these first couple of panels today, are opportunities for us
to see how people are doing integrative, alternative,
complementary, holistic practice in the community in various
different kinds of settings. In fact, that is going to be
the focus of much of the day.
I am hoping that what we will do with each panel,
is, after they give their brief statement, we have a lot of
time for discussion, or a significant amount of time for
discussion, and it will be asking them the questions about
service delivery that will focus on ways of delivering
services: what is effective; what is not; what is cost-
effective; how is it working in their community; how is it
working in their particular setting.
We will have plenty of time in subsequent sessions
to come back to issues of licensure, education, and
research, but these are the folks we brought in specifically
because of their expertise in service delivery. So I want
to remind us all of that so we can focus on and get the most
out of the sessions.
Okay, next will
DR. Charlotte Eliopoulos.
DR. ELIOPOULOS: I am here representing the
American Holistic Nurses Association, an organization of RNs
that is committed to mind, body, spirit healing.
The nursing profession has a long history, and
perhaps the longest of any health care profession, at
providing care in a holistic manner. We believe that a
holistic approach to care is essential to the healing
process.
We are enthusiastic supporters of the integration
of CAM as part of a holistic comprehensive plan of care.
Providing a CAM product or therapy without assessing and
addressing the total needs of the person really risks
perpetuating a system of fragmented care and really dilutes
the beneficial outcomes that are potentially available.
To nurses, it is not a matter of CAM or
conventional care, but really using the best of both worlds
to achieve optimal results for clients.
We believe that nurses must have a significant
role in this integration of CAM into the health care system
at large, and there are several reasons for this.
First of all, being that nurses represent the
largest group of health care professionals, over 2 million
of us out there, in a wide range of clinical settings as
diverse HMOs, emergency departments, hospice programs, home
health, and on and on and on.
Our education prepares us to coordinate care, and
responsibilities that nurses have assumed for probably as
long as our existence has been one of coordinating, and it
seems reasonable to think that we could also coordinate the
integration of CAM with conventional practice.
Nurses are uniquely educated, I believe, in first
of all recognizing abnormality from normality in their
assessment process, to be able to identify needs that fall
within the realm of biological, spiritual, socio-economic
and so on, and finding the right resources to meet them.
Coordinating the efforts of a multi-disciplinary
team, I think, has been a unique nursing function, and using
a wide range of services to provide care, and also to
evaluate outcomes.
Nursing standards really emphasize advocacy of the
client, so protecting them in their use of CAM, in their
integration of that into the health care system, seems
reasonable.
Nurses also recognize the cultural and the
psychological and the spiritual needs that affect health
care choices and practices.
Nurses are ethically, professionally and legally
responsible for protecting clients and advocating for their
well being, and also nurses enjoy a high degree of consumer
confidence.
We believe there are a number of actions that
nurses can take to facilitate the access and delivery of CAM
products and practices, first of all, being to increase our
own knowledge base through continuing education for the
existing work force, as well as the integration of this
within the undergraduate nursing programs, also to stimulate
the development of systems to help with the access and
delivery of these services.
I am speaking of things such as assuring policies
and procedures are in place within the existing health care
system to assure that services are being safely utilized,
and so on.
Advocating and demonstrating a holistic approach
to the delivery of these services is also important, and
also for nurses to derive private practices where they can
utilize some of these therapies themselves, which many of
them already are. They are doing it in terms of helping
people with developing healthy lifestyle practices, managing
chronic conditions in a natural manner, and coordinating the
services of both conventional and CAM practitioners.
The AHNA supports an integrative approach to the
delivery of CAM products and services, and we recommend that
reimbursement and policy decisions be made to facilitate
that, and that part of those decisions need to consider some
reimbursement for nurses to facilitate the assessment, the
coordination, the monitoring of the utilization of these
services.
Also, that nurses be looked at as well prepared,
cost-effective coordinators and monitors in, using a catch
term, gatekeepers of these services. They have got a
history of demonstrating they can do this with conventional
care and it certainly would make sense to utilize that
expertise.
We thank you for this opportunity to present a
voice for nursing on this commission. Thank you.
DR. GORDON: Thank you.
Mort Rosenthal is next.
We have a couple of corrections here. The
testimony should be behind Section V, Tab C, and we need to
replace page 8 and 10 of
MR. Rosenthal's testimony. I think
Joe gave you those sheets.
MR. ROSENTHAL: I don't know what is on page 8 and
10, but I deny it.
I am the chairman and founder of Well Space. Well
Space is attempting to consolidate and brand the CAM market,
making it safer and more accessible. We believe we are
creating a consumer benefit, a practitioner benefit, and we
believe that there is a business opportunity created by that
consolidation.
Brand will mean safety and quality in the
consumers' mind, which will help create access.
We opened a prototype center in Cambridge 27
months ago. We have 21 treatment roo
MS. Since then we have
seen 10,000 patients, excluding our classes. We have had
about 40,000 visits. To give you a sense, we are open 90
hours a week, seven days a week. We employ 70
practitioners. This year we will do about $2 million and we
will make some money on that, not enough, but some money.
Not enough to justify their role.
We offer many modalities of massage, acupuncture,
Chinese herbs, chiropractic, naturopathic medicine and
nutritional classes. We see about 100 new patients a week.
We get 60 percent of those from referral, from ear-to-mouth
referral. Twenty percent drive by, or walk by, and about 10
percent from medical referral.
We treat a whole range of conditions. About 45
percent of our visits are related to stress, or relaxation,
and the rest are specific medical conditions like pain,
headaches, back and neck pain, sleep disorders,
fibromyalgia, fatigue, everything to cancer.
We are complementary, not integrated. We are
attempting to create an idealized delivery system for health
care, and have concluded that that necessitates a system
that is neither modeled after nor dependent on the existing
health care system. When you do something in CAM, there are
not barriers and legacies that you would have to deal with
in more conventional care.
To be successful, and I think we are pretty
successful, it requires a real business focus. I think to
be sustainable, whether you are for-profit or not-for-
profit, you require that business focus which is on
operational excellence, quality service, and cost control.
A lot of that is driven by the fundamental
economics of the CAM industry. A successful CAM
practitioner, with the exception of certain acupuncturists
and chiropractors, probably
will make between $30,000 and $60,000 a year.
The margins that we get in our business are about
33 percent, which means that we charge 1-1/2 times what the
practitioner takes home. If you look at traditional health
care, conventional health care, the multiples are between
three and seven times. That means there is a whole lot more
margin to play with in the delivery system. If you look at
any service business, the multiples are typically three to
seven times for accountants, lawyers, et cetera. So the
margins are tight, and that means we have to focus on
expenses that are focused on quality service and
affordability. We have a heavy investment in systems and
processes that allow us to deliver consistent quality from
visit to visit.
Another key aspect is simply the attention to our
customer, to the patient. Patients are making a choice to
come to Well Space. They needed to be treated like a
customer, with the single overriding principle being that
every touch is an opportunity to deliver care and create
loyalty.
For example, patients never, never, never wait for
an appointment. The money transactions are done easily and
simply. Appointments are available when a patient wants
them. If education is needed, it is done in a
nonthreatening, informative and sensitive environment, and
the physical environment supports the mission in terms of
appearance and all of the other senses that are fed by
walking in by walking in the door at Well Space.
The other key part of what we do well is attention
to the practitioner. In CAM, perhaps more than other forms
of health care, the practitioner-patient relationship is
really critical, the best practitioners definitely have the
best outcomes. So we need to attract the best practitioners
in order to be successful, and we need to focus on them from
an economic perspective, from a policy perspective, and from
a cultural perspective.
So our practitioners are attracted to a community
which is both within their modality as well as the cross-
multiple modalities, so they can practice with other
professionals. It is a very professional working
environment, and notes are filled out on every visit, for
example. Their practices are managed so that all they have
to do is deliver the care. They don't have to worry about
anything else. Their compensation is probably better, but
it is certainly more reliable than it would be in private
practice, and they get benefits that are otherwise not
available.
We have a heavy investment in systems, as I
mentioned. There are three key systems: resource planning,
which drives utilization; appointments and point of sale;
and finally, medical records. Whereas, I said we developed
a system that allows for a point-and-click creation of a sub
note based on our modalities.
Briefly, I want to talk about our relationships to
physicians. We have excellent relationships with local
physicians. We do get, I would say, referral, but I put
that in quotes. It is more you should try Well Space, or
you should try acupuncture, as opposed to a traditional
referral.
Importantly, our patients are simply not
interested in integrative care. We have the capability to
create progress notes. Literally nobody has asked for
information to go back to their physician in 40,000 visits.
Finally, a bit about managed care. We did a pilot
study with 2000 lives that were given essentially free
access to CAM without medical referral, without any pre-
existing condition. In a six-month period, about 70 people
took advantage of that. Of the 70 people, when we completed
the pilot, of the 70, about 50 continued to come and pay out
of pocket. I think what that says is that there is not a
lot of price sensitivity in this market. If you are in
pain, the cost of the pain far exceeds the cost of the
acupuncture treatments to address the pain or something like
it.
From a policy perspective, very briefly, I think
the delivery system for CAM will continue to be largely
stand-alone. Of the $20-odd billion, I would say 99 percent
of it is delivered by individual entrepreneurs who are
practitioners, whose success is a function of their
outcomes, because otherwise their clients will not come
back. I think any policy needs to not necessarily have a
bias in favor of integration, because otherwise I don't
think it will work.
Panel Discussion
DR. GORDON: Thank you very much, all three. I am
sure there are a lot of issues that we would like to discuss
with you.
Who would like to begin?
Let me start then.
Bob Atkins, I want to ask you what your sense is,
both of the economics of your practice, the economics and
sort of economic and social aspects of your practice? And
also given the fact that you are an extraordinarily well-
known author, what are the implications for other people who
are not so well known, although they may be reasonably well
known in their communities?
DR. ATKINS: Well, it is a tough question because
being well-known has really changed the demographics of our
patient population. Some 40 percent of the people now come
from so far away that their follow-up has to be done through
telephone counsels very often, and only an occasional visit.
But most of my career, practicing that way wasn't like
that.
Basically we started off just being part of the
system. In other words, when they had insurance, we applied
for insurance, and they got reimbursed that way. Every once
in a while there would be proble
MS. There are certain areas
of care that we are very happy with that are being
suppressed, and one of them, the first one that comes to
mind is the high resolution microscopy that is very much a
part of our diagnostic system.
With this microscope, which was an expensive
investment, we can see the material between the red blood
cells. We can make diagnoses of various bacteria, yeast
parasites, because we actually see them in their
characteristic way of clustering under the microscope.
Now we were told by CLIO that we can't do that,
that we have to basically close that down. This is going to
be a very painful part because so much of our understanding
of patient care was based on that.
Then various states, of course, have --
DR. GORDON: Do you want to explain what CLIO is
and what that means?
DR. ATKINS: Well, that is a laboratory
surveillance, so to speak, group. And they said yes, we
love your lab, you get 100 percent success, but high
resolution microscopy doesn't have any codes for it, so you
can't use it. So that is typical of many of the obstacles.
In treating cancer patients, of course, it is a
disaster because the treatments that we read about or that I
learn about when I go to international conferences, and I
see that they are the most successful treatments that are
alternative to chemotherapy and radiation, such as
hyperthermia, which I am very pleased with. But there are
no legal hyperthermia devices that will provide whole-body
hyperthermia legal in the United States so we have to go to
Europe or Mexico, and send our people there.
There are an awful lot of other therapies that
have not been approved. Treating multiple sclerosis, we
found a very effective treatment, AEP, calcium AEP
injections. Legal in Europe, but not in the United States,
and they are not even allowed to bring into the country, and
yet it is a perfectly safe and innocuous nutritional
treatment which has, in my own experience, caused neurologic
improvement in about 200 of my MS patients.
So there is a very long list of obstacles that we
have to face, and now, of course, we have got the HMOs and
things of that nature which mean that the people aren't
going to be reimbursed. Not reimbursing for chelation
therapy, which has been really the mainstream of cardio
prevention for thousands of physicians who practice CAM, and
so this is not reimbursed by Medicare, and therefore the
major insurance carriers don't want to carry that
reimbursement.
Many states, of course, have different laws. New
York State, we finally got a law passed which acknowledges a
physician's right to practice alternative medicine, and in
so doing, they no longer can just take our license away just
because we do things differently.
I think the important thing is that having a right
to do things differently is very important. You asked me
what the problem is. I want to talk about the solution
because the solution would be to get the kind of research
done that would allow people, the government and other
people of interest, to see the two systems compared with a
matched group of subjects to see whether or not our
assertion that we get better results and at a lower cost
than mainstream medicine has been getting.
DR. GORDON: Thank you very much.
Tony, Bill, and Tom.
DR. LOW DOG: Part of what we are trying to do is
to determine access and delivery, and I just want to commend
everybody, and I thank you also for bringing the nursing
perspective which we had not really heard, and who, by the
nature of their profession, are very holistic.
But my question is really directed at Well
Springs. It sounds very exciting, what you are doing over
there. One of the things about access is who can afford it,
who can pay for it. We have already discussed
reimbursement, and that is going to be a separate session,
really, but do you make attempt in your services for sliding
scale fees? Do you have a day a month where there is a
reduced fee schedule? How have you worked to address
providing to the community for those who cannot afford $60
for an hour of service?
MR. ROSENTHAL: Couple of things.
First of all, there are discounts available that a
practitioner can offer to someone in need at any time.
Secondly, we certainly encourage our
practitioners, who generally work exclusively with us, to
also work in some sort of giving back to the community
environment. Obviously reimbursement is potentially the
solution.
You know, our prices are not that high, and I
think the point about the cost of the payment exceeds the
cost of the treatment, and even though people have an
expectation to not pay for their health care, you know,
spending $200 or $300 for a course of acupuncture that
addresses a migraine issue you have had for years is pretty
trivial. And, in fact, we don't have a great sense of
household income, but we have done surveys of our customers.
It is surprisingly low. This is not only an affluent
community that comes to Well Space.
DR. LOW DOG: Could you give us an example, of
like an hour of acupuncture treatment?
MR. ROSENTHAL: Acupuncture treatment is $60. You
know, the intake is $85, and the treatment is $60. But you
can go down to $40 if the need arises.
DR. LOW DOG: Thank you.
DR. GORDON: Bill?
DR. FAIR: I have several questions for
MR.
Rosenthal.
First of all, you addressed a couple of times that
Well Space is not going to represent integrative practice,
but rather complementary, and since we are talking about
access, I had questions relative to this.
Since your clients really didn't their physician
to be involved, first of all, how does that make it
complementary? It would seem to me almost separate.
Secondly, when you had that pilot project, 2000
people with the HMO, and only 70 took advantage of it. What
recommendations do we have? What did you learn out of that?
In 70 out of 2000, when it was a free benefit wasn't really
impressive.
MR. ROSENTHAL: No, it wasn't impressive. I would
say let's answer the second first.
Right now, as I said, reimbursement is not
something that -- obviously the costs go dramatically up,
particularly when an HMO is trying to do something unusual,
the costs are even higher. So you can imagine what the
costs are. And the discounting is relative to a retail
price. So literally for every visit, we lost money. But it
was still worth trying.
I think the message is that not that many people
know about CAM or believe in it. The people who do will pay
for it. But the people who don't, don't know about it. So
there is certainly a policy goal of more education which
would then make it not 70, but 700.
It was disappointing. We expected an increased
demand to at least be something we would learn from it. But
I think education is the key thing.
On the issue of complementary versus alternative,
I mean we certainly established the company with the goal of
it being complementary. As I said, we have full sub notes
which is a pretty substantial cost. We can generate
progress notes. We expected a lot of exchange on our
initial intake for
MS. You would fill out your physician,
there would be a check box, we will send the physician the
note, and literally I think was zero people checked that
box.
So my point was not a matter of opinion, it was
just a matter that the patients simply do not view them as
connected. Maybe they don't view them as connected because
they go to their doctor when they are sick, and they go to
Well Space, at least to some degree, when they are healthy,
or when they are sick of going to their doctor.
DR. FAIR: We heard a number of presentations
yesterday that heart disease and so forth, the theme was
always there throughout all these presentations, or for
cancer, if only I had known about this before I got sick,
before the defining event, I would have changed my life. I
guess it comes back to education, but I wondered, it seems
to me, and I said this yesterday, we are not doing a very
good job in education. We have this epidemic of obesity and
increasing risk of diabetes in people in their 30s, and it
has been estimated that probably at least a third of cancers
are diet-related, and another third are probably related to
other lifestyles, and it seems like we are not getting the
point across.
So have you learned anything that this condition
could say this would increase accessibility or acceptance of
CAM, from your experience?
MR. ROSENTHAL: Certainly, again, it is not like
we have an easy task of getting people to come from a
preventive perspective. Generally speaking, people come
when they have some issue they are going to address. We
have tried to put programs together that are oriented to
that, and they have not been wildly successful. So we don't
have any real experience of that. I think education is a
key part. There is an awful lot of preventive CAM and non-
CAM treatments that are not reimbursed. Certainly that
would help.
DR. FAIR: The last question. I commend you for
the idea of the sub notes because that is so foreign to many
of the modalities that are represented by CAM, and it seems
to me a tremendous resource for outcomes down the road,
although you say you are not sure what to do with them.
But was that a system that you had to develop
within Well Space, or was there a commercial system that you
went to, to do that? Because that really is essential if we
are going to get the information. That would improve not
only research, but accessibility.
MR. ROSENTHAL: We did develop it based on an
existing system. We created our own vocabulary and so you
point-and-click with a TCM diagnosis and you point-and-click
on the points, et cetera, as an example acupuncture being
sort of the most different kind of system.
We have 40,000 records that have got to be useful
to somebody. But because there is not an ITD-9 code from a
diagnostic perspective, because there is not a CPT code for
the treatment, nobody knows what to do with it. And that
may be because we are in Cambridge, you know, and Harvard is
certainly the bastion of something in traditional medicine.
But you would think that someone would be able to figure
out something to do with our 40,000 records.
DR. FAIR: And these are all computerized, aren't
they?
MR. ROSENTHAL: They are all computerized, and
they are all reasonably structured. It is not free text.
DR. GORDON: Tom.
MR. CHAPPELL: Mort, my question for you, I would
like to understand better the decision that you made about
complementary, not integrative, and then I would like to
understand the compensation arrangements a little bit better
for the practitioners. What were the driving factors for
you to choose to select out MDs from the services?
MR. ROSENTHAL: There are basically three reasons.
One was that we were concerned about hierarchy.
You know, if you put a physician in, and it would be an
exceptional physician who could practice literally alongside
a CAM practitioner on an equal footing. But the physician
would want to control the care, and we were dubious about
whether any physician could really do that effectively. So
we didn't want to create the hierarchy, point one.
Point two, competition. If we had physicians,
then conceivably we would get referral from other physicians
and other practices. In Bottener, there are several clinics
that do have physicians, and they have generally not done
well.
The third issue is we are an entrepreneurial
organization, and we are trying to be successful. Sort of
messing with reimbursement, messing with the traditional
health care system is just not a good way of being
successful. So we just decided to avoid it from that
perspective.
MR. CHAPPELL: Do you revisit it?
MR. ROSENTHAL: With some regularity. And we have
lots of physicians who would like to practice in Well Space,
and we have a number of efforts or discussions to
essentially put a Well Space inside of a health care system,
but still sort of a separate box, with a door.
On the compensation issue, practitioners are
compensated about a third with salary and two-thirds with
incentives. The incentives are largely based on number of
visits, but there are also bonuses for utilization and for
retention. So essentially we try to incent them to do a
good job.
MR. CHAPPELL: I assume these practitioners are
on the payroll and not on a referral?
MR. ROSENTHAL: Most of them are full time, but
not all of them.
DR. GORDON: Okay, I have Don, Charlotte, Effie.
Anyone else? And then David.
DR. WARREN: On that question about access, the
access problem is that we can advertise alternatives and
complementaries, but unless we have the practitioners to
take care of those people, what do we do, to the nurse? I
see a big chance for nursing to educate the physicians and
make it their idea. Many times you go in and you try to
beat somebody up with this, they go up the wall. But if you
can slowly integrate it, and I see the nursing as the
fastest way to integrate complementary alternatives into
medicine, it could make it the physicians' idea through the
back door, kind of. What do you think about that?
DR. ELIOPOULOS: Well, I think nurses have
educated physicians for a long time very tactfully. I would
like to not put it in the framework of a manipulative, that
we are helping the boys understand this is their idea. I
really think we are in a partnership. And I think part of
our education is to educate about a new model of care
delivery where the leader of the team does not necessarily
have to be a physician with this integrative model. I think
that takes perhaps a bit more than education to make that
happen.
What I am hearing about in some of these other
models, I have to question if maybe people don't want or
haven't asked for records to be transferred because of the
lack of education, because nobody sat down and helped them
understand that there has to be a marriage of these
therapies, and I think nursing does have a crucial role with
that.
DR. WARREN: Well, I see patients not wanting
records because they don't want to be insulted at their
doctor's office. You know, to take those records and say I
am using this nutrition, and all of a sudden they are
lambasted because they just make expensive urine.
DR. ELIOPOULOS: And I think that is why it is
important, and I think this is where nursing can play a
vital role, because nurses are in these private practices
with the physicians, and they are in the hospital settings
and elsewhere, to be able to buffer some of that, to provide
some of the education, to be able to sift out what is a
fantasy here versus what is a real therapy that can be
effective.
DR. WARREN: So we are dealing with a lot of frail
egos.
DR. ELIOPOULOS: We are dealing with some of that,
yes.
[Laughter.]
DR. WARREN: Thank you.
DR. GORDON: Okay. Charlotte.
SISTER KERR: This is specifically to Charlotte.
Thank you for your presentation.
Aspects of CAM are integral to nursing, touch,
listening, time. The nurses were the first to know that
self-care was primary care, or at least equally with the
others.
I also notice that historically, and it continues
to be, and I still don't understand why, nursing is even
being in many ways still marginalized today. There is a
crisis in nursing. And just as I was listening to you, I
thought, you know, as nursing is seemingly getting to be
more of a crisis and being diminished, CAM is rising.
Historically it seems like the nourishing functions, the yin
functions, the affective functions, the listening functions,
is what we have refused to pay for in health care, at least
in the experience in nursing.
So having said all that, I wondered what could you
offer, what could you envision, what coaching do you have to
give to us, both in the area of CAM and even policy, based
on your experience in nursing? And if not now, later. And
very specifically. Because you have been there and we got
this.
DR. ELIOPOULOS: And it may be that I will need to
come back with some recommendations to offer some specifics.
You know, I do think that some ongoing advocacy
for the fact that it is a healing process, it is not just
really throwing modalities into the pot. Now those
modalities are important, and the reimbursement for them is
important. But there is a process, a healing process, that
needs to take place, and at some point we have got to put
the rubber to the road and say we are going to commit to
this and reimburse for this, or we are not. Or are we, as I
say, just have additional fragmented care, using a different
set of modalities in the pot?
You are right with what you say about nursing. We
are having a crisis, and I think it is because we cannot
function in the healing arts as many of us have been
nurtured into a profession to believe that is unique to us.
I think our association manages to attract people who are
frustrated with the conventional health care practices, and
want a different path, want a different practice, and are
carving out some unique practices to make that happen. But
unfortunately we are tied into systems where our paychecks
come from some pretty conventional sources and dictate what
our practice modalities look like.
SISTER KERR: Thank you.
DR. Atkins, when you spoke, you actually gave a
preface, in my opinion. You were talking about paradigm
shift. And you said there was a new definition of system of
health care.
Charlotte, what you are saying is talking about
the need, as I often say, acupuncture is a process, not a
procedure, and you were speaking to that in terms of what we
are about, not just adding on new modalities.
My listening at the moment is speaking to the fact
that we need to, perhaps, as
DR. Atkins said, is continue to
have a conversation, and we are talking about what we are
about here, is to talk about are we talking about a change
in the system, or are we talking about -- do you think that
that is important, that before we talk about the
reimbursement of this or that, that we need to actually
speak to that in our education to the public about what we
are about here? Would you agree with that? Or
DR. Atkins,
you are shaking your head?
DR. ATKINS: Absolutely. I see no reason why the
practitioners of mainstream medicine don't begin to add more
and more complementary therapies into their thinking. I
really think that there has to be a whole movement away from
specialists to the ultimate idea of a generalist, a person
who knows everything. I think that is a noble ambition for
a doctor to try to achieve, and I don't think it is
difficult to do. I think it is quite possible that a doctor
begins to learn if he can't do acupuncture, he knows the
role that it plays, he knows the role of all the herbal
therapies, he knows the role of the nutritional therapies,
and he makes decisions on the basis of what will be the best
choice for this particular patient.
That seems to me to be the only direction which
will change the way medicine is practiced for the better in
the future. If we keep them separate, if we keep the
alternate treatments separate from mainstream medicine and
allow mainstream medicine to proceed in its direction of
making us the nation with the highest health care costs in
the world, and they are doing that because of financial
considerations, I do believe. When surgery is being offered
before you give a person a chance to reverse the heart
disease, to give an example, that is money.
Complementary physicians specialize in reversing
heart disease once people have been told that they need a
bypass, but to do the bypass before they get out of the
hospital is the problem.
I think we have to confront the mistakes that are
being made by my colleagues in mainstream medicine, and
complementary techniques are the answer. They are the
potential answer, the potential way to prove to everyone
that this is the way medicine should change over the next
few decades. I think when that happens, we are going to be
very surprised at how health care costs go down, how
hospitalization statistics go down, and how we will be able
to handle all the Medicare problems that we are so concerned
with, because they won't be quite nearly as expensive.
SISTER KERR: Thank you.
One last follow-up questions. You said -- I'm
sorry, I forgot your name for a moment. You said, of
course, reimbursement is the solution and will enter into
reimbursement, although in your paper on policy
recommendations you mention that the best practitioners with
the best outcomes don't necessarily choose reimbursement.
I want to suggest that maybe reimbursement is not
the solution. What do you think about that? My experience
is it is such a botch-up, and --
MR. ROSENTHAL: The existing model of
reimbursement is clearly not the solution, and some sort of
subsidy, conceivably, for people who cannot afford care may
be the solution, or medical savings accounts with the
subsidy at the low end. Again, a range of things.
Certainly for existing models of reimbursement,
from an administrative perspective, do not work for CAM,
period. They really, really don't, and the idea of
negotiating a fee, again, remember, traditional medicine
before managed care was say seven times what a doctor took
time. They were billed out at seven times. There is a lot
of room for administrative cuts, there is a lot of room to
negotiate the fees down. When you are billing out at one
and a half times what is a not very high salary and you want
to discount that, where are you going to go? You can't take
costs out of the operations, so therefore an acupuncturist
with five years of experience, instead of making $45,000, if
they are still doing it, is going to make 30? That doesn't
seem right. So I don't think reimbursement is the right
answer.
SISTER KERR: Thank you.
DR. GORDON: Effie, and then David.
DR. CHOW: I also want to thank you for the
report, and my question is directed towards the nursing. I
appreciate the role of nursing and the role that we can play
as mother, father, and companion, and overall role. One of
the aspects of nursing is that we are also facilitators, and
networking, really creating the ambience for healing and
caring to take place. I wonder if the American Nurses
Holistic Nursing Association, what is your role at working
with other organizations, like the American Holistic Medical
Association, or even American Nursing Association, to
facilitate better in terms of eligibility and even education
and so forth?
DR. ELIOPOULOS: We have just started. It has
actually been a week past in terms of our networking with
some of the other organizations. We do network with other
nursing organizations, and there is the umbrella of the NOF
and the VASNO umbrella, nursing organizations, especially
organizations that do meet regularly and exchange, and we
actively participate in that. We share our views with those
organizations and exchange programs and thoughts with them.
We are developing a position paper. We have a draft of a
position paper on the nurse's role in complementary and
alternative medicine that will be shared, and hopefully
endorsed by all these nursing associations by this time next
year. So that networking within nursing is stronger, I
think, than with the AHMA and some of the other
associations. We have started conversations with them about
doing some joint educational conferences and exchanging
materials, but that is about it. We have not taken a stand
together for positions. It has just not been the way our
associations have functioned. Not out of a lack of desire.
I think it is been out of a lack of organizational,
administrative strength.
DR. CHOW: I hope that would be something you
would consider.
DR. ELIOPOULOS: It is a goal now. It is
certainly something that is important to us.
DR. GORDON: David.
DR. BRESLER: This is for
DR. Atkins. We are
talking about access, and it seems to me no matter how large
your facility is, there are still just a finite number of
people that can come through your program. However, you
have leveraged your program by writing books that takes at
least part of your program out to huge numbers of people.
However, you have no interaction with those people in terms
of being able to do lab testing and the other things that
you do in your facility. How comfortable are you with using
books and print media as a way of getting greater access to
the information you use in your program?
DR. ATKINS: Well, I don't consider the books a
way to get access. I hope they will get people to make a
phone call, and then we work out a system. Sometimes we
have quite a system of nutritionists who can do a lot of
telephone consultations, but that is inadequate.
I think our greatest contribution are seminars we
hold for physicians who would like to learn our kind of
medicine. We expect that each year when we hold one, we
expect to get a much larger group. We are pretty certain
that there are more and more physicians who are going to
practice this way. All we have to do is remove the fear
that their license will be revoked, and once we do that, the
doctors want to do it. It is absolutely amazing. When we
put out an ad for staff physicians, more and more people
respond, and these are people who really don't have training
in alternative or complementary medicine. They just want to
learn it. And then more and more people attend our
seminars, and we are not the only ones to have seminars.
Quite a few other seminars are held, and more and more
people join. More and more people seek membership in a
group like ACAM, the American College of Advancement in
Medicine who are over 1000 members now.
So I think the access is going to be through more
and more physicians who emulate the people at our center,
only practice in their own towns, their own cities, their
own states, and I think that will be the answer.
DR. BRESLER: Thank you.
DR. GORDON: Wayne will be the last questioner for
this panel.
DR. JONAS: I had a question really to
MR.
Rosenthal and to
MS. Eliopoulos. There are a number of
models of nurse management in conventional care, especially
oncology where nurses kind of become patient advocates and
are the communicators between the radiologist and the
oncologist and the primary care physician, and looking for
clinical trials type of thing.
I am wondering, that type of a model as a health
educator or coordinator of patient care, is that something
that either of you have talked about in your organizations
or considered? Is there a need for it? Is there something
that patients would like, or only a certain percentage?
Does that look like a way of kind of at least bridging a
link between these what appear to be two fairly parallel
systems that don't communicate very often?
MR. ROSENTHAL: We have a function that we call
Well Space Guide, where again when we were setting up the
company, the assumption was the guide would be sort of the
gatekeeper for a lot of clients who were coming in and
didn't know what to do.
In reality, the guide is requested or used maybe
by less than 5 percent of our visits, and really only when
we force it, like we have a back and neck pain program where
you have to see the guide as a sort of starting point. And
so that is surprising that it was so little.
In other words, it is mostly people who know that
they want acupuncture or know that they want to see a
naturopath or whatever.
We considered and interviewed some holistic nurses
for that, and certainly the idea of a nurse playing that
sort of bridging role would make a lot of sense. Again, it
has not been utilized very well. We ended up hiring someone
who is an acupuncturist/massage therapist/occupational
therapist, basically has a range of skills. But mostly it
is around, you know, connecting to a patient in a very sort
of easy way. But certainly that would make some sense, but
it is not a huge demand.
DR. JONAS: In your population, people kind of
know what they want and they come in, and they seek it out
individually. I imagine, though, in other groups, for
example, oncology patients, patients with cancer, or if
there were to be an effort to make this more proactive to
provide access to a wider population that did not have kind
of this knowledge, that perhaps that might be more important
in those circumstances.
DR. ELIOPOULOS: That is what I would like to
respond to, because there are some nurses who are developing
that kind of practice, both as a private practice as well as
within some conventional settings.
I know I have a limited private practice myself
where I perform that kind of service for people with chronic
conditions. And what I find is that I am working with a lot
of people who don't know what they don't know, in terms of
what options are out there, both within conventional
medicine as well as some of the CAM modalities. So my role
is to help educate them and refer them to practitioners, and
to monitor what is going on, and to make sure that one hand
knows what the other one is doing. I think it is a very
viable role for nursing.
MR. ROSENTHAL: It is not like people coming in
knowing exactly what they want. We have a relationship, for
example, with a large cancer support group in Boston. We
speak there regularly, so they come in through that door,
and they are referred to a practitioner who may be
particularly good at a condition.
DR. JONAS: Thank you.
DR. GORDON: Thank you very much.
I want to take just a couple of things. One is
that I really appreciate the questions the Commissioners are
asking, as well as responses. I feel like we are really
getting to some of the issues.
I would encourage the panelists, and all the
panelists who come today, that out of the questions and out
of the dialogue we have, to really think on as large and
ambitious and hopeful a scale as possible about some of the
issues that we are all discussing, and to make
recommendations to us based on what is coming out of this
experience, as I think especially these last few questions
were pointing out. We are really looking to see how this
health care system can be responsive to people's needs and
far more effective, and our task in a sense goes way beyond
attention to CAM.
The other thing that I want to mention is that we
have an hour at the end of the day, Charlotte, to address
some of the questions that you are raising. I think it is
really important that we be thinking about these as well.
Tom and Joe.
MR. CHAPPELL: May I ask one question of the
panel?
DR. GORDON: Okay. But we really have to move on
because we are already a little behind.
MR. CHAPPELL: Mort, are you finding branding to
be successful, or a successful way of economic
sustainability, as opposed to reimbursement?
MR. ROSENTHAL: That is say a consumer coming in
of their own choice. Yes, I would say our problems are not
in creating consumer demand. We have a good brand in the
Boston area, and it generates a fair amount of visits. So I
would say that in our case, branding is sufficient.
I also wanted to invite any of you who happen to
pass through Cambridge to come to Well Space, because we are
a delivery system which is bricks and mortar, and actually
seeing it is interesting.
DR. GORDON: Joe, did you want to say something?
DR. FINS: Just a question for
DR. Atkins.
In your statement that was supplied to the
Commission, you talked about informed consent, that you
wanted to follow the recommendations of the New Jersey
Supreme Court, saying that conventional practitioners have
to provide patients with information about alternative
therapies.
Let me really turn it on its head and just ask you
about access and safe access, and the safety issues.
What happens in your program when a patient fails
your modality? I am sure that there failures in allopathic
medicine, and there are failures in complementary
modalities. What kind of safeguards are there that that
person has access to the conventional modalities and is
quickly and appropriately referred to a cardiologist,
perhaps for bypass? What kind of mechanisms have you guys
used to ensure the safety of patients in that situation?
DR. ATKINS: Well, basically, all of us are
trained as physicians, and whenever we see a problem that we
think requires the need of someone whose specialty allows
them to handle it, we make the referral right then and
there. So we have never gotten into that kind of trouble
because we refer things out whenever there is the need to do
a referral. So it is something we haven't had to deal with.
Remember, you have to understand that, yes, we add
complementary therapies to our program, but we are basically
very well trained internists, and our instincts are those of
a well trained internist.
DR. GORDON: Great. Thank you again.
We will take a five-minute break and then we will
have the next panel.
[Recess.]
DR. GORDON: Will the panelists please come to the
table.
Thank you very much.
Again, as you will see when you look at the
schedule, this group of panelists will be focusing on clinic
situations in which they play a leadership role, and they
will be presenting the models of CAM or integrative care
that they are offering.
First will be Tom Trompeter. Good morning, Tom.
MR. TROMPETER: Morning. Thanks for this
opportunity to speak with you once again.
Before we get started, I know that when we were in
Seattle, a number of you asked me some questions that I said
I would get back to you on. November is usually a rather
busy month. We have got a couple of major grants that we do
in the early part of December, so that was really kind of
occupying our time. But I will provide you with answers to
those questions, either on kind of an ad hoc basis today, or
in writing, in a more formal way, some time between now and
the middle of December.
You all posed four questions, and I would like to
just kind of run through them, not quite verbatim as it is
in your book, but as a way of sort of starting the
conversation.
My name is Thomas Trompeter. I am the executive
director of Community Health Centers of King County. We are
a private non-profit, tax-exempt organization, with a
consumer majority board of directors. What that means is 51
percent of my board of directors is comprised of patients of
our health centers. We have six medical and four dental
clinics in suburban Seattle, probably comprising about 50
miles between the two furthest ones.
Each year we provide about 90,000 visits for
people who are all poor and primarily uninsured. About 95
percent of our patients have family incomes that are below
200 percent of the federal poverty guidelines. About 75
percent are below 100 percent of federal poverty guidelines.
A little over 40 percent of our patients have no insurance
at all. Those that do have insurance are generally insured
either by Medicaid or by what in Washington is known as the
Washington Basic Health Plan, which is a managed care
product designed for people primarily with incomes below 200
percent of poverty, who pay premiums on a sliding scale.
When you all asked why and how did we decide to
provide CAM products and services, I think context is also
key. The Puget Sound area, I think, has for a long time
been a rather fertile ground for integrative medicine and,
in fact, not just our corporation, but the other community
health centers in the area have had intermittent
experiments, I guess is one way to say it, in providing
integrative care.
At various points in time over the last 25 years,
various health centers have tried to employ naturopathic
physicians, for example, although economically it has not
always worked out.
In 1995, due to some advocacy work that was being
done throughout the community, an opportunity was created
for us to compete for a grant that would help us establish
an integrative medicine clinic, and in that process we
developed a partnership with Bastyr University which is, I
think, well known to most of you, to begin an integrative
clinic.
What we did was we basically proposed a response
to a request for proposals that had three components.
One was that it include conventional primary care,
another is that it include at least some elements of
complementary and alternative medicine, and the third
component was that it include an evaluation component.
We successfully competed for that grant, and that
is what really got us off the ground financially to start
this clinic. We opened our doors on October 21st, 1996.
Secondly, you all asked -- and actually, I would
like to back up a bit. There was a fairly firm commitment
from our board and from our administrative leadership to
pursue integrative medicine, and I think that really helped
set some organizational context for us to move forward on
this. We don't move in policy directions like this without
the approval of our board of directors, and it was very
critical for us to have a consumer board interested,
supportive, and actively involved in this process, and they
were.
In asking how do we determine which products and
practices to make available and for which conditions, on the
which conditions side, I would just like to say we are a
primary care operation, and the conditions for which we
offer CAM services are the conditions for which people
normally seek primary care.
We have referral relationships with specialists
and hospitals, and we do use those for folks who present us
with conditions that are beyond our scope of practice.
When we responded to the RFP for the King County
Natural Medicine Clinic, the clinical leadership from both
Bastyr community health centers, with input from our
administrative staff at both organizations, identified four
disciplines that we would include in the initial
organizations.
Those disciplines are naturopath medicine,
acupuncture, chiropractic, and therapeutic massage.
In addition, we decided initially to offer
naturopathy and acupuncture on site and to offer
chiropractic and massage via referral.
The decision to offer some services on site and
some via referral was driven by two main concerns: the need
to use limited resources wisely; and the need to offer in-
house those services for which we all felt that we possessed
sufficient expertise to be able to provide appropriate
quality assurance.
That is, we could not afford to offer all four on-
site, and we wanted to be able to do on-site that which we
could do best.
For chiropractic and massage, we would then
establish contractual relationships with community
providers, whom we trusted, to be able to provide not only
high quality care, but who would also have the necessary
non-clinical skills to provide care to the particular
patient populations that we serve.
Just as a sideline, a little over 30 percent of
the visits that we provide require the presence of an
interpreter. This is not the norm in the private practice.
We had hoped that over time we would gain the
necessary skills and necessary funding to provide both
chiropractic and massage on site, and in one small step, in
May of this year, we hired a licensed massage practitioner
to provide on-site therapeutic massage via referral from
providers throughout our system.
DR. GORDON: Tom, I think what we are going to
have to do is, we have read the testimony, and we will have
a lot of questions during the question period. Sorry to cut
you off.
MR. TROMPETER: That is fine.
DR. GORDON: Next will be Sylver Quevedo.
DR. QUEVEDO: Thank you. My thanks to you all for
this opportunity and to you for your pioneering efforts in
this area.
My name is Sylver Quevedo. I am a physician and
nephrologist and the director of the Center for Integrative
Medicine at the O'Connor Hospital in San Jose, California.
I come to you very much from the perspective of a
conventional physician in practice and also involved with
the teaching of medical students, residents, and fellows.
I have five points, and I will be brief.
Integrative medicine is the medicine of the
future. Any hospital not looking at it will be seen as
obsolete within 10 years from now.
The second point, conventional bio-medicine needs
the broader perspective of integrative medicine to thrive.
These are bad times for hospitals and academic medical
centers, as many of you know, and the broader perspective of
integrative medicine will be revitalizing for the
conventional ranks, and it is necessary.
Integration is essential, and it is largely
occurring even by virtue of the process we are engaged in
today. However, programs which look at it up front and take
it seriously will have an advantage in the years to come.
Culturally appropriate care is predicated on a
respect for the life, world and culture of a given patient,
and integrative medicine takes this perspective seriously,
not relegating it to the realm of psycho-social factors, as
often happens in the narrow bio-medical model.
Belief matters, and this perspective, I think, is
honored in the integrative medicine vision.
Lastly, credentialing strategies are essential for
hospitals and academic medical centers, and they must be led
by physicians with standing on the medical staff in order to
be successful.
Let me elaborate on a couple of these points in
the time remaining, but again, I will leave most of this to
the questioning period.
The first point, that integrative medicine is the
medicine of the future, in the materials that I have
provided for you, I took some pains to spell out what we
mean or what we meant in our efforts by integrative
medicine, and they were not limited to a discussion of a
given modality, but attempted to reach the deeper traditions
of medicine and the healing traditions around the world.
We drew on the work of
DR. Gordon and others, and
worked hard in our discussions to make it our own, to
understand it and articulate it for our own groups. This is
what I mean by integrative medicine being the medicine of
the future. It is, I think, incumbent upon us to look
deeply at what we are doing in conventional medicine, asking
questions about why it is no longer seen as effective, why
is there such great dissatisfaction both among practitioners
and patients alike.
Regarding conventional bio-medicine, as powerful
as new technologies and scientific advancements have been,
the broader perspective of integrative medicine brings us
back in conventional bio-medicine to the larger cultural
process of which we are a part. We can no longer simply be
about the business of medicine or science without paying
attention to the larger cultural forces and, indeed, the
perspective that many consumers have, that there is
something much greater than science when it comes to
healing.
Lastly, culturally appropriate care in our
increasingly pluralistic society is a necessity, something
that we need to look at very hard, something that, without
taking it seriously, will simply make what we do in
conventional medicine less and less effective. And in order
to do that, we need to think in terms of the broader culture
and the healing traditions from the cultures that patients
come from, and to realize that belief matters very much. We
are no longer regarding it as an afterthought. It needs to
be brought into the main stream of conventional bio-
medicine. This should be part of what occurs in medical
schools and medical training progra
MS.
Lastly, regarding the credentialing issue, it has
been important for us to work actively with members of the
medical staff to develop a strategy that they could feel
comfortable with, and I will simply conclude by saying that
initially much of the resistance that we encountered from
the medical staff was simply based on the fact that they had
very little familiarity in these matters, and as we began
this dialogue, that resistance has largely melted away, and
they are now asking us to organize a department of
integrative medicine in the hospital and to bring these
therapies into the in-patient setting.
Thank you.
DR. GORDON: Thank you very much.
Woodson Merrell. Good morning.
DR. MERRELL: Thank you,
DR. Gordon and other
members of the Commission, for the chance to be here today.
I was actually told that I would not be presenting any
remarks at the beginning, so my remarks will be fairly
brief. I would say that with
DR. Quevedo, I feel like we
must have been separated from the hip in terms of many
things we have to say about the philosophy and background of
medicine are very similar, particularly the aspect of
integrative medicine being the future of medical care.
I am just going to mention a few things in terms
of the direction of my questions that I was given about the
Academic Centers incorporated integrative medicine. In
terms of that background, I am the executive director in New
York City of the Beth Israel Medical Center's Continuing
Center for Health and Healing. This is an integrative
medical center that was in planning for about two and a half
years, and just opened in June of this year.
It comprises 16 clinicians, nine physicians, and
seven allied health and CAM providers, covering most aspects
of integrative medicine in a hospital-based practice.
The hospital held a think tank about two years
ago, and they actually got it, they understood that this is
the future of medicine, and the patients are increasingly
using it, that they don't know really what to do for many of
the therapies that they are using, very few reliable
information sources. Someone is going to do it, and it
might as well be them.
So they put together a team of people to set up an
integrative medical center that would be academically based
and that would combine the best of the traditional healing
practices that have been around for centuries or millennia,
look to them to be increasingly evidence-based, and combine
that with the best of conventional western bio-science.
There are many complementary medical centers in
academic settings around the U.S. The majority of them are
primarily research and education, or they have clinical
programs there that are very small ones, primarily focusing
on mind-body. Not that that is not important, and of course
it is the most important aspect of the field, but I think
there is a lot of trepidation in terms of incorporating any
of the other aspects of CAM into traditional academic
settings.
At Beth Israel Center, we actually have all
aspects of research, education and clinical care on an equal
sway, and we provide the patients access to most all
treatment modalities and approaches within CAM.
We are part of an academic hospital setting. Beth
Israel Medical Center is a teaching hospital of the Albert
Einstein College of Medicine, and it is actually very, very
focused now integrating integrative medicine into all
aspects of training.
The medical school itself just had its first
working group with the Dean of Education and the Dean of the
Medical School committing to integrating integrative
medicine teaching into every course of all four years of
medical education at Einstein, and we so far have been able
to do that for about half of the courses, and after our
first meeting.
We are incorporating the medical students in all
four years being able to rotate through our center and the
residency progra
MS. At Beth Israel, we actually have the
nation's first required residency rotation in integrative
medicine, which is a one-month rotation in the family
medicine department as a template for trying to train not
only medical students, but physicians right now in training,
because of course a big part of the problem is that even if
you wanted to deliver these services, who are the
practitioners that should be delivering them. There are
very few people who are trained in aspects of complementary
medicine in any kind of an organized fashion.
So the third part of this, besides medical student
and residency education, is fellowship training, and we just
received the funds to set up a two-year fellowship in
integrative medicine at our institution, and we will be
working with Andrew Wyles Fellowship to really try to set,
through fellowship training, what are the standards of what
an integrative physician actually does in practice.
One of the things that the focus of this group
here today is about is access. We are primarily a private
practice model, and we may not have time in this session to
get into it, and I know the next people will be talking
about it more. But it is very difficult, in terms of the
current managed care system, when you are reimbursed 30
cents on the dollar, when your overhead is 50 and 60 cents,
to make a go of it. So our clinic is primarily fee-for-
service based, with prevailing rates for faculty-based
practice.
We do have a number, though, of access points for
people who are uninsured, or underinsured, including what we
call a Helping Hands Fund. Right now we have raised $50,000
to provide free care for people who don't have medical
insurance.
We have a number of other clinics, they are Title
28 clinics, within the medical institution. Fortunately,
Beth Israel who for the last decade had been providing CAM
services to the underserved and minority populations, and
although through the fellowship and research programs, we
will be able to provide access to patients at a reduced fee.
Our fellows will actually be paid a small stipend for the
patients that they actually see, and these are board-
certified physicians in primary care who will be able to see
patients at a reduced rate.
The last point I would like to make before I close
is the role of CAM providers, the integrative knowledge of
the physicians being knowledgeable in integrative medicine
in terms of practitioners working together. We see it as
critically important that most licensed fields of CAM be, if
not all licensed fields of CAM, be incorporated in these
centers, particularly an example being chiropractic.
I personally feel that chiropractic has an
important role to play in integrative medical systems, not
only because of the services that they provide,
increasingly. Over the last decade, as patients are
becoming disenchanted with the medical care system and their
physicians, they turn to CAM providers.
I can't tell you how many patients that the
chiropractors, as their primary care doctors -- bringing
chiropractors into the primary medical care system --
actually allows those patients to come back into the
traditional medical care model.
The role of nursing I will discuss a little bit
later.
Panel Discussion
DR. GORDON: Great. Thank you very much, Woody.
And for somebody who wasn't prepared, you did a great job.
Thank you all three. It is a tremendously fertile field for
us to explore.
Who would like to begin with questions? Conchita,
and then Joe, and then George, and then George.
DR. PAZ:
DR. Quevedo, I would like to find out
what some of your specifics are as far as the culturally
appropriate medical care that you use in your clinic.
DR. QUEVEDO: One of the most important things to
address in this issue, I think, is language. Now our
particular program at this point in time is in a community
hospital, it is a private hospital, and we have seen many
new patients with limited resources, but it is not the same,
for example, as the hospital I was at just before, which is
the County Hospital in San Jose, where we did see many
patients that are indigent, et cetera.
But having said that, I think one of the most
important things is language, but it is not only language,
but also belief syste
MS. I think the important point I
would like to make to you today is that we used to think in
terms of culturally appropriate care as a problem for a
given ethnic group or racial group, et cetera, and I would
simply like to suggest to you that all of us operate in a
given belief system, and that belief matters. This is a
perspective, I think, that has been forward by integrative
medicine, understanding, for example, mind-body connections,
et cetera. It is revitalizing because it takes us out of a
narrow sectarian dialogue and into a much broader dialogue
which is more fundamental, and I think more compelling for
the future.
DR. GORDON: Joe.
DR. FINS: I just think it is interesting to note
a paradox here, that the for-profit entities that we heard
of this morning that are outside of the mainstream
reimbursements mechanisms are more viable than you guys who
are trying to do it within the appropriate back-up and
physician interaction.
For example,
DR. Quevedo, you have a screening by
an internal medicine doctor before any referral occurs,
which seems to be very prudential.
I would just like to ask you and
DR. Merrell about
this paradox and the similarity that mainstream academic
medicine has, that the cost of providing care in those
settings is more expensive.
So what kind of funding strategies would you
recommend to allow the integration, which I think provides
added value and ensures safety? Either one of you, or both
of you.
DR. MERRELL: I think it is very difficult for
these centers at the moment to exist without private
funding, and I think certainly governmental grants are good,
but it takes a long time to get them, whether it is for
research or other progra
MS. Private funding sources are
really the white angels of this field. We wouldn't have
been able to do it without being funded privately for start-
up and operating for the first year. You can't possibly
make money for a minimum of three years in most business
plans, and increasingly medical centers are no longer able
to foot the bill for this. So I think looking to private
funding and developing those sources in the community is a
critically important area.
One thing that our institution did that I am
surprised, but it apparently is unique to most institutions,
is have the hospital recognize the importance of what we are
doing to the existence of the medical center, and to the
medical care system. They actually made this a part of the
mission of the hospital, to develop integrative medicine
services, and thereby they threw open the doors of the
development department, so that the trustees and donors
lists were given to us and they were actually courted by the
development office with us, to bring additional funds in.
Seeing it really lessens turf battle between the
departments, because this is coming into one big pot for the
institution of the whole. It is going to help it as it
makes its transition from hospital-based to more ambulatory-
based care in the future.
DR. QUEVEDO: I would just mention a couple
things. It is certainly true that we are doing more than
just taking of patients and developing progra
MS. We are
working on the institution, and we don't get paid for that,
and that is a lot of work.
There is another perspective, and that is that we
have argued with the hospital that there is a value added to
what we are doing, that it is changing their image in the
community, et cetera, and that has worked to some degree.
But admittedly it is hard to do this kind of work in these
institutions with so much institutional inertia, heavy
overhead requirements, and cost burdens, et cetera.
DR. FINS: Do you guys feel that there is an
uneven playing field, that you are providing more and yet
you have to compete with people who are not providing all
these services, and yet in the marketplace you are competing
against some of these other venues?
DR. MERRELL: I wouldn't put that in a proprietary
model because it is based on whatever the funding source,
venture capital, whatever. I often wanted to open a center,
franchise it, et cetera, not that proprietary centers don't
have a place, but certainly when you don't make the bottom
line, usually the first things to go will be research and
education, and then shortly after that all of a sudden you
are going from your average 22 minutes per visit to let's
ratchet that down to seven minutes a visit, pump up the
volume, we need to make some money here. And I think that
academic centers provide a little bit more cushion in terms
of looking at the mission to be a global mission. Of
course, the bottom line is important, but it is on equal
footing with other aspects.
DR. QUEVEDO: We actually deliberated three
scenarios that included a venture model, a joint venture
with the hospital and a private group, and as part of the
hospital. And for many of the reasons similar, we decided
not to go in a proprietary mode.
DR. FINS: What about the budget for your
commitment to furthering the research and educational needs
of this developing area?
Thank you both.
DR. GORDON: George.
DR. DeVRIES: Thank you.
DR. Merrell, most academic medical centers are not
including chiropractic at this time, and yet that has been
somewhat unique in including chiropractic in its integrative
clinic. And not only that, you indicated that it is
critical, that chiropractic is playing a critical role in
your clinic. Can you expound on that, especially if there
are issues of access, like what patients you are attracting
because you offer chiropractic, or other variations that you
see?
DR. MERRELL: I wouldn't say critical is the right
word. I think it is very helpful to have chiropractic
involved. I mean similar care could be administered by
osteopaths, for example, but chiropractors do have a unique
role to play, and they are often as team members of the
community. So I think incorporating them into the system
provides an important modality.
There is no doubt about the fact that there is an
incredible entrenched opposition to including chiropractic.
It used to be the same way with acupuncture, but that is
considered almost more mainstream now. It seems to be a no-
brainer, where five years ago I thought if I even mentioned
it at my medical school, I would have been booted out. It
has been quite a change.
I think that it is institution by institution. It
is really the luck. I mean what you are able to depends
upon which people in key places have had personal
experiences that have transformed them, or understand, for
whatever reason, the importance of this field.
At our institution it happened that the Chairman
of Physical Medicine and Rehabilitation thought chiropractic
was an important modality to look at, and to have the
services available, and so therefore helped champion it
through the credentialing committee. We have actually
developed credentialing guidelines you have in your packet
that I provide you, the first guidelines in Academic Center
in New York, to have a credentialed chiropractor,
acupuncture, massage group within an academic setting that
was developed by a committee that consisted of the Chairmans
of Medicine, Surgery, and the resident curmudgeon skeptic
who would, if he signed off on it, everyone felt that this
was something that would be acceptable. There was a lot of
hammering out in terms of language and scope of practice.
But some institutions just won't be ready because the
orthopedists, or whomever, there are large groups that won't
allow it to happen. But it is something that I think
increasingly will be looked at more favorably.
DR. GORDON: George.
DR. BERNIER: I would like to ask
DR. Merrell in
terms of the educational programs that you have been able to
put forth, you clearly have an integrated educational
program in terms of CAM practitioners and traditional
residents.
Have you looked, at the same time as you have been
doing that, at integrating the educational programs for the
more traditional health providers, like nursing, allied
health? Is that folded into one program?
DR. MERRELL: It is beginning at the medical
school, primary medical school education, but particularly
at our institution, nursing plays an equal role in terms of
educational access. I mentioned, in answer to one of your
questions that you gave me, that really nursing plays a
critical role, particularly within the hospital, and so they
are the ones who are on the front lines, who will help
really to transform the institution. Physicians often don't
have time really to do this, and partnering with nursing is
very important.
Medical schools are realistically more difficult
to develop joint programs with, with nursing, with
dentistry, or physical therapy or other allied health
progra
MS. I think within the hospital or the medical
center, it will happen first before it actually becomes
capable of being integrated in the medical school setting.
DR. BERNIER: If I could ask
DR. Quevedo, do you
have educational programs built into your enterprise?
DR. QUEVEDO: Not to the extent that
DR. Merrell
does. We do have medical students who have rotated with us,
and we do have a relationship with the family medicine
residency that is part of the Stanford Medical School. But
that has been informal.
We are actually involved in discussions with the
department, actually the Division of Family and Community
Medicine, about the possibility of a fellowship that would
be after family medicine residency training, a fellowship in
integrative medicine.
At Stanford, the family medicine activity is a
division in the Department of Medicine, and so what we are
talking about is a fellowship which would be a training
program in that division.
DR. MERRELL: I just have one quick thing to add
about our nursing. In our center, we have a nurse
practitioner who is a solo practitioner, who also works
beside being family medicine and Ayurvedic medicine, but we
also have a clinical nurse specialist who actually is a
person who provides what I would call holistic consultation.
So when patients come in, if it is unclear whether they
should be in our system, she is kind of the point person for
doing a consultation to decide where they should access
which care, if they are going right to the physician or, in
our system, a patient does not have to see a physician
first, they can go directly to a CAM provider if they so
choose, and it is often the nurse who helps them figure out,
based on their history, where they might need to go.
So we see that as a kind of focal point of
information for patients in triage.
DR. BERNIER: Thank you very much.
DR. GORDON: Tom.
MR. CHAPPELL: With regard to access, could I ask
the gentlemen who have the medical hospital model, can you
assess competitively in any way, or have you assessed
competitively in any way what were the consumers' interest
in coming to the hospital versus a private entrepreneurial
option, or other options? Another option, the community
model? Do you have any idea how appealing your model is?
DR. QUEVEDO: Well, I would say we haven't done a
formal study on that, but I can give you some impressions.
One thing that we have found is that many patients
who are already in the hospital community, whose physicians
are at the hospital, et cetera, have been quite happy to be
able to explore issues in complementary medicine, et cetera,
with us since they regard us as part of the same community.
Having said that, some patients are still nervous
about talking to their physicians a lot about it, but they
at least feel that they can address it with us and have us
act as an intermediary, to some degree.
But we also have many patients that are self-
referred. When we initially designed the program, we had,
largely because of considerations with the medical staff,
had planned to have internal medicine evaluation pretty much
for everybody. But there were many patients who simply
wanted to come for massage therapy or more specific reasons,
and who already had physicians who were very actively
involved as their primary care physician. So we relaxed
that, and we have patients who are self-referred as well.
Whether they have chosen us because we are
hospital-based or not, at this point it is hard to tell.
Our impression is that it is important for us to encounter
patients where they find themselves, and that is often in
the conventional mainstream of medical care, and that is why
we did it in the hospital.
But I want to emphasize one other side to this,
and that is that as much as we have done it from that point
of view, the hospital and the medical community has been
enriched by the activity, immeasurably. It has been
revitalizing for us.
Many of you know hospital committees that are
really pretty sleepy activities. Our committee was one of
the few committees where people were calling in advance to
find out when the next meeting was, et cetera. So it was an
experience in professional renewal for me, and I was really
impressed by it, because I hadn't seen that for years in a
hospital.
MR. CHAPPELL: Thank you.
MR. TROMPETER: I would like to respond a little
bit. I think from the communities that we are in and our
patients' standpoint, there is really no difference between
what we are and what a private entrepreneurial practice
might be, I think from an operational standpoint, and what
motivates us. But, frankly, when we opened, there was a
fair amount of outreach and publicity that was conducted
both by us and others who were excited that this was
happening. We had people coming directly to us that were
coming to us because we had both modalities under one roof.
It has been a very popular service with our patients, both
those who have no money and no insurance, and those who do.
And actually the economic mix of the folks who come
strictly for the natural medicine clinic is a little bit
different than the economic mix of the folks who come to us
for other services. Not enough to make it a go on that
alone, but kind of an interesting switch.
The other thing that I think our experience and
DR. Quevedo's experience is very similar, we developed this
rather elaborate protocol for informing patients of their
options and their choices and ways of making sure that
people knew what they wanted. We were open a month before
we gave it up, because people absolutely knew what they
wanted to choose. I think that that in itself was a bit of
a bellwether.
MR. CHAPPELL:
DR. Merrell, do you find this much
the same as your colleagues?
DR. MERRELL: Yes. I think that we decided to
open in a facility actually outside the medical center
physically, so we felt that patients would not exactly want
to be streaming into a hospital in New York City to be
getting CAM services.
Also the quality of the practitioners, I think, is
key, because unless you have high quality practitioners,
preferably who are known in the community, you open a clinic
in a hospital where no one really knows the practitioners in
the community, it is very hard to get much volume of
patients coming in. So we strove to find people who were
very well respected in the community to bring into the
center.
MR. TROMPETER: We have also found other
corporations in the area have come to us and asked us to
come and talk to them about how we have done what we have
done, so that they can do similar things.
DR. GORDON: We have Linea, Bill, Charlotte,
Wayne, and Julia. We have three minutes left.
MR. LARSON: Thank you. I will speak very
quickly.
This is probably a little bit of a conundrum, it
is a conundrum for me.
MR. Rosenthal stated that they did not allow
physicians to practice because of the reason of inability to
not work without hierarchy, an inability to not be able to
work alongside with other practitioners at equal levels.
You,
DR. Quevedo, stated that it was important that a
physician in good standing within the community be the
director of this integrative clinic.
Does that have to do with access to physicians who
would be approving and supportive of the services, rather
than the patients coming in and valuing a physician as the
director?
DR. QUEVEDO: Let me understand. What I said is
that for credentialing strategies to work, they need to be
managed as an inside job, essentially, by physicians who are
in good standing.
Now let me preface this by saying that much of
what we have done in contradistinction to Mort is that we
have been working in a hospital environment, and that has
mattered in terms of our strategy and our approaches.
Let me also say that physicians certainly do need
to change many of their sort of habits, but personally I
have not seen them as resistant as it sort of appears from
the outside, once you open this door. Practically
clinicians and the people that are in practice, they are
dealing with uncertainties and widespread consumer
dissatisfaction, and they are really unhappy with managed
care every day. I mean the time is right for them to begin
thinking outside their box.
So I think there is fertile ground there, but that
dialogue needs to be marshalled by people to some degree
that they feel safe with, and that is, I think, the role.
Now admittedly, this is not necessarily what
patients are concerned about. This is work for doctors with
doctors. But my own belief if that they are an important
resource, and if we have learned anything from this entire
movement, it is that self-care, including healing the
healer, is an important activity and professional renewal
matters, and all of those things need to be managed as well.
This is the part that I think has been good for us.
DR. GORDON: Before we go on to Bill's question,
could you just give us a few words of description of what it
has been like within a hospital environment? And even more
importantly, what lessons you would have us learn from your
experience working in a hospital.
DR. QUEVEDO: Again, for me, it has been
enormously revitalizing. I have been around hospitals for
most of my 25 years in medicine, and the last period has
been enormously difficult, as all of you know. So
personally it has been great.
What has it been like the institution? The
culture of hospital management right now is sick. It is a
difficult culture to deal with. It is a culture that came
out largely of the non-profit sector and is focused on
expense and cost management, and is trying to deal with the
new business culture that really doesn't understand. It is
a culture that is searching for a new mission, and many
people who are really doing the best they can, working very
hard, but frankly, pretty burned out about a lot of things.
So it is a difficult environment.
But as I mentioned to another physician who asked
me the same question, why do you want to bother with this,
and I said the thing that is important to me about this is
that physicians and hospital workers, et cetera, are an
enormous resource. Amazing things go on every day, and they
do amazing things and give unselfishly every day. If we can
find some way to articulate a vision which gives hope and
resurrects the feeling of joy in this work, reminds them of
the sacred nature of our work, et cetera, that
revitalization will result in an enormous outpouring of
effort and work and creativity which I think will be
sustaining in the future years. Beyond that, it is
essential right now. These institutions are literally dying
without it.
So having said all that, there are some hard
things. I was talking with someone earlier about the
difference with what Mort Rosenthal is doing with Well
Space, we are investing effort in dealing with the hospital
and the academic medical center and nursing and physicians.
I might mention one last thing, and that is that I
think that holistic nursing is a profession which already
has contributed, in fact, was pioneering in this effort, but
in hospitals. If it takes its rightful place in hospitals
it can be enormously important in the future, and we have
tried to develop a model where we use holistic nurses as
case managers to contribute to the effort to integrate and
coordinate care.
DR. GORDON: Thank you very much.
Bill.
DR. FAIR: Woody, thank you for your presentation,
and I think you deserve congratulations for pulling this
off, if you will.
We are talking about access and delivery, but
clearly underlying that is credibility. Unless the medical
schools, the teaching hospitals, accept this as an integral
part of medicine, I don't think -- I think the battle for
credibility will be uphill, so I think that what you are
doing is extremely important.
Along that line I had a question. In the New York
area, the Columbia Center opened and closed within a short
period of time, and that is my entire knowledge of the
mechanisms or the factors behind that, and I think the
downstate program is sort of hanging on. So my question to
you is from the apparent failures of those two academic
programs, have you learned something, or is there something
you could share with the Commission that would maybe
influence our recommendations for stimulating the delivery
of CAM services within academic programs, which I think is
so important?
DR. MERRELL: I think there are two main reasons
for the failure, and one was political, and that means
relationships, and the other was funding. Each one had
problems in one or the other or both, and there are other
centers that have opened with great plans in academic
settings that have also had difficulties. I think it is
very important for relationships to be nurtured, the kinds
of things
DR. Quevedo was talking about, in the institution.
If you don't really nurture the relationship with the
thought leaders in the medical center, to have them
understand that you are really doing a responsible medical
practice that is going to enrich patient care and focusing
in on as much evidence basis as you can, that you are going
to be fighting an uphill battle. You may have one or two
key people, but with another eight or 10 prominent people
backstabbing, it is going to be difficult to make a success
of it. So I think that is one aspect.
The other is funding, and it is very difficult
within the hospital. In the hospital it is difficult to
deliver the services because in terms of DRGs, how do you
carve out, out of a surgeon's cell, getting massage or yoga?
And that was an area of contention particularly at
Columbia. And the other is just in terms of if you are
going to accept managed care, how you actually can be
financially viable, and that is a very difficult issue that
I think if I get into that, we will be here all day. So I
will just say that was a main issue, and that we are
primarily fee-for-service at the moment, but trying to
develop a relationship with insurance companies to have them
recognize the value of what we are doing, and by the data
that we are capable of accumulating to look at the cost-
benefits.
Not being a big fan of the managed care system, I
will say, though, in their defense, they aren't a lot of
cost analyses to show what works and what is cost-effective,
and we have an ability at these centers, particularly the
academic ones, to be able to begin tracking that for them
and being in partnership with the insurance companies.
But it was primarily underfunding, managed care,
reimbursement difficulties, and particularly bad politics
within relationships between the CAM centers and the
institution.
DR. GORDON: Thank you for the answer. And since
we will be coming back to reimbursement, maybe you can help
us with what you are learning about fee-for-service and
managed care and what some of the difficulties are, and then
help shape our recommendations for that as well.
Charlotte.
SISTER KERR:
DR. Quevedo, when you gave your
presentation, I heard several times belief matters, that
people understood that there was more than sciences related
to healing. And then you again said language and belief
matters, and then you said belief matters. So I wonder
specifically --
DR. QUEVEDO: Just believe it.
[Laughter.]
SISTER KERR: -- how is that essential to your
work? And does or can this have implications for policy?
DR. QUEVEDO: Good question.
Is it essential to my work, and how do I
incorporate it, is that a fair restatement of the question?
My own culture, my own experience, has led me to
know many different experiences with healing. But I was one
of these folks that loved science. I mean I loved Western
science, and I think when I was less aware of my own
spiritual development, I think a lot of what drew me to
science was not so much what was known, but what was not
known. In fact, I was attracted to the mystery of life, and
the mysteries of nature.
Now as I understood over time that there was a
part of me that was much broader simply than a given
empirical representation that the natural world would
describe, I realized that this is also occurring for
patients.
Now when I was in medical school in my early years
of training, this was largely represented as in the category
of psycho-social factors, somehow outside the realm of the
hard sciences, and not nearly so important as biochemistry,
et cetera, et cetera.
Yet, as every clinician knows, these factors are
enormously important in the case of patients, and sometimes
are more powerful than a given drug, et cetera, and
determine behavior.
What I have learned in my own explorations of this
newer view of medicine, this newer vision that I call
integrative medicine, is that there is a biology of belief,
as Herb Bensen has called it, that we know from studies of
the placebo response, et cetera, from much of the work that
many members of the Commission have done in the area of
mind-body medicine, that this is not only about culture and
philosophy, but it is also about biology.
So I would simply say to you that once I had
incorporated that into my own thinking, my own belief
system, I have taken quite seriously the act of being with
patients and listening to them, practicing presence, as well
as trying to work with their conceptions of reality and
translate across cultures. And very often that is with
people who are educated in America, et cetera, et cetera.
We are still working across cultures.
DR. GORDON: Thank you.
Wayne, and then Julia, and then we will close it
down.
DR. JONAS: Well, Charlotte, as usual, you have
stolen the most profound question.
[Laughter.]
DR. JONAS: So I am going to have to backtrack to
the more mundane issues. I think if anything comes out of
this Commission, if we can get our money and our minds
together, or perhaps more appropriately our health care and
our heart, we will have succeeded, regardless of what else
happens.
I am specifically interested in how much activity
CAM practices are actually going on in-patient, because this
is an area that I haven't really seen touched very much, and
is an avenue that perhaps has some rich potential. Could
you comment a little bit on that? Are there practitioners
in the CAM area making rounds, seeing patients in the
hospital, making suggestions, working with physicians under
those conditions?
DR. QUEVEDO: I can tell you what we are doing.
The Center for Integrative Medicine at our particular
hospital is now about 18 months old. The credentialing
strategy, which was largely to set up an ad hoc
credentialing committee that reports to the medical
executive and also to the credentialing committee of the
medical staff, we report quarterly to the medical-executive
body, et cetera. That strategy has been largely seen as
successful, as acceptable, and where there have been issues
raised regarding process, we have had a structure in place
to deliberate them.
Out of that, an interesting thing happened. There
were a couple of patients in the ICU who requested
acupuncture. One was an Asian patient who had head trauma
and who had sensorium changes, and the neurosurgeon and
internist taking care of the patient did not want to use
sedating drugs because they were watching neurologic signs,
et cetera. The family of the patient requested that his
headaches be treated with acupuncture. The internist and
the neurosurgeon, because they knew of the center, asked for
it as a consultation.
Our agreement with the medical executive body had
been that we would limit the scope of practice and our
credentialing to the out-patient setting until we gained
enough experience to make recommendations to go beyond that.
So we declined the opportunity to provide acupuncture in
the in-patient setting, and the ICU nurses and the nursing
director were really disappointed.
The chief of staff asked me to represent the case
at the NAC meeting following that, and as I was getting
ready to do it, the chairman of anesthesiology and critical
care did it for me. She said that it was really a tragedy
that we couldn't provide this, since we have gained all this
experience in the out-patient setting. That led to a
unanimous resolution by the chiefs of departments to create
a credentialing strategy to bring selected therapies into
the in-patient setting.
At the same time the hospital was cited by the
Joint Commission for having too narrow an approach to pain
management, being excessively pharmacologic in orientation.
So the anesthesiology chair and the surgery chair also came
to us and said would we participate in designing a CAM
strategy to be incorporated and make their JACO response
look a little better. And so we did that, and that is
targeted to start in January 2001, and we will be bringing
massage therapy and acupuncture into an integrated pain
management team that will be actually run by the department
of anesthesia.
The formula that we are using is that we are using
the Center for Integrative Medicine as a proving ground to
credential and evaluate potential practitioners for the in-
patient setting, and then the CIM, the Center for
Integrative Medicine, and the credentialing committee of our
center will make recommendations to the credentials
committee of the medical staff.
Without having the groundwork, the credentials
committee chairman basically said, you know, we wouldn't be
able to do this, because they didn't want to deal with it,
essentially. So that is what has happened here, and we are
planning to start that in January. Up to this point, it has
been a little bit of massage therapy and that is it, really,
in the in-patient setting.
DR. MERRELL: We have credentialed both in-patient
and out-patient chiropractic massage and acupuncture for CAM
services, and then anyone who has a license essentially can
do mind-body therapy, whether it is a Ph.D. or RN, NP, et
cetera, and that already exists and actually our nursing
program has developed, with the approval of the chairs of
the department of surgery, a pre-op surgery program that
provides patients with imaging hypnosis before Reikian
therapy and touch during and after surgery, institution-
wide. What is required in credentialing is that in order to
have chiropractic acupuncture in the medical setting, the
attending physician of the hospitalized patient has to
request it, and actually the chair has to approve it, but
the chairs have all said that they approve it if the
attending asks for it. So they don't need to go to that
second level.
We are just beginning now to have chiropractic
available in the spine center for low back pain and
acupuncture beginning particularly for post-surgery
patients. So we are just open five months, so we are just
beginning to get into the in-patient settings, but the plan
is to expand it and make it available to every department,
and more than that, have each department have their own
people so they don't keep calling us in to provide the
services, but that they take ownership so it is integrated
to their department. Not that it is some boutique or
separate department that is occasionally providing services
to the institution.a
DR. GORDON: I'm sorry, I am not sure I
understood. You are providing all the services, or they
have their own providers?
DR. MERRELL: No, at the moment, we are providing
them, so we want them to provide their own, eventually. We
are helping to work with them to actually -- if they want
there to be a department of integrative medicine, eventually
there will be, but not to provide services throughout all
the hospitals, more to provide guidelines on credentialing,
to try and coordinate things. But we really hope that each
department, in and of itself, will hire the practitioners to
do their own services, so that it is not one separate
department, but each department takes ownership. Right now
we are the only game in town, so practically we are doing
it.
DR. GORDON: So you provided the credentialing
system that has been accepted by the hospital, and then
within that system, they would then hire their own people?
DR. MERRELL: Yes. Each department could hire its
own people with the same credentialing guidelines. It is
not just for us, it is for the whole institution.
DR. GORDON: Do you have any sense of the demand
that might occur in this, or how many patients can actually
request it, use it, or --
DR. MERRELL: Yes. The demand is huge in the
surgical program, and in-patients that come in already have
increased the patients using chiropractic and acupuncture,
have already started asking for the services. It is only
the fact that we don't have enough personnel to schlepp over
to the hospital to do all these things has prevented us from
doing more in-patient work, because the patients, now that
they know this is available, they are beginning to request
it.
DR. GORDON: Maybe one of your fellows could be an
exploratory venture into a CAM hospital. Is there something
like that?
DR. MERRELL: To the fellows, that will be a
definite role for them.
DR. GORDON: Julia.
MS. SCOTT: Thank you.
This is for
DR. Merrell. Earlier one of the
Commissioners asked if these CAM services were available to
the underserved, underinsured, and medically unserved, and
you responded that these populations were served by two
affiliated clinics. My question is, are the CAM services
offered different than those at the academic center? And if
so, what are the differences?
DR. MERRELL: No. I think this is a unique
situation. I was trying to figure how you could make this
applicable to the rest of the nation, but we are in a
uniquely fortunate situation. Actually the department of
family medicine is hooked up with the Institute of Urban
Studies, and for 10 years has had a Sidney Hillman center
that originally was private, now state-funded to provide
care to the uninsured, underinsured Medicaid, and they have
been routinely providing care and nutrition and nutritional
therapies, Chinese medicine, acupuncture, mind-body
therapies to patients with classes on yoga and massage,
meditation, tai chi, and that has been for over a decade.
There is also a clinic that is semi-private, but
is actually affiliated with the hospital, that serves
primarily Hispanic and African-American population. That
has also for decades been providing those services. Again,
it is a Title 28 facility, largely state-funded, providing
all those services. So we are fortunate in that we couldn't
afford financially to make a go of it just serving a high
percentage of the population, but within the system we have
it worked out so that that is already available.
The formula of how you incorporate all that under
one roof obviously requires a degree of subsidy in a center,
unless it is a fairly bare-bones set-up.
MS. SCOTT: Thank you.
DR. GORDON: Thank you. Thank you all three very
much for the richness of the presentations.
We will take a five-minute break, and then we will
have the next panel.
[Recess.]
DR. GORDON: We are going to begin with the next
panel now, so if the panelists can come forward, and the
Commissioners can come sit.
One of the things I want to say at this point is
to very much thank the subcommittee that has worked on this
program, and also our staff. This has been a labor of love.
Part of the labor of love has been to orchestrate a program
in which we see both specific examples of different kinds of
integration and different kinds of CAM programs, and at the
same time we are enabled to take a larger view. This is one
of the larger-view panels.
We have two people on the panel who represent
managed care organizations, and a third, Lori Bielinski, who
works with the Washington State Insurance Commissioner and
has a major role in helping to design and implement plans of
health care. So, in a sense, it is a kind of -- I don't
know what you would call it, oversight supervisory
regulation.
What we are going to do is we are going to begin
first with James Dillard, and then Anna Silberman, and then
Lori Bielinski will be third.
So, James Dillard.
DR. DILLARD: Thank you,
DR. Gordon.
I am glad to be here to talk to you. I am an
acupuncturist chiropractor and medical doctor. I have had a
chance to do a lot of different things in the alternative
medicine arena.
In 1995 and '96, I was asked to consult with
Oxford Health Plans based in Connecticut at that time, still
is, basically doing business in the tri-state area of New
York, New Jersey, and Connecticut, to help build a
comprehensive CAM program inside the insurance company.
DR.
Rasama That was the business director, I was the first
medical director in October of 1996.
We built a program, and I am sure many of you are
familiar with the program. We credentialed almost 3000
providers and six provider types, and went live January 1 of
1997. It has been a model program in many ways, and pretty
successful.
Unfortunately, the company had some financial
challenges at the end of 1997, their stock dropped
precipitously, and so it has been an interesting but in some
ways an incomplete experiment in building a CAM program
inside a managed care organization, simply because we have
had financial challenges since the beginning of 1998 until
recently.
Fortunately, the company has done a very
remarkable financial turnaround and is one of the more
solvent insurance companies, managed care companies, in the
country right now, thanks to our CEO,
DR. Norman Payson.
The reality is -- and you can ask me more
questions about the program, if you like -- the reality is
that a lot of managed care companies aren't doing so well
financially. Ten years ago they were the darlings of Wall
Street.
Now, they are not considered to be great
investments. A lot of them are having trouble making
profits, difficulties with their projections, and I think it
has changed the whole environment for building these kinds
of programs inside managed care. It has become much more of
a challenge.
Our chief medical officer, Alan Muney, would want
me to tell you that we really should not endorse or try to
weave in things that don't have very strong evidence,
because the reality is that we just can't pay for it right
now. We have limited resources. We don't want to have
things that represent duplicative services, that may have
marginal outcomes.
The idea of somebody seeing the acupuncturist and
pulmonologist for their asthma at the same time, that are
certainly additive costs. We don't have the kind of data we
need to comprehensively dovetail these things. But the
Oxford program is still a very interesting model. It is a
three-tiered model consisting of standard benefits, an
alternative medicine rider, and contracted network of
providers, what we call affinity plans being referred to as
now.
But the question also comes down to, where are you
going to spend the money. We just don't necessarily have
the money to do everything for everybody as is necessarily
wise or even effective.
I think the Oxford program did represent access
inside a large managed care company which was considered to
be one of the silk-and-satin plans on the East Coast. It
was middle class, upper middle class, upper class. We
insure a lot of the big Madison Avenue fir
MS. It was part
of the boutique quality of the plan, and continues to be a
major part of its identity today.
I can address some issues of integration, trying
to create integration inside a managed care organization.
We made some, I think, successful attempts at that. In some
ways, we were not able to fully execute, even though our
plan was pretty good, because of the financial challenges of
1998 and 1999. Some of those plans are still on the drawing
board, and we may have the opportunity to carry some of
those things through.
There are a number of barriers to that
integration. There is resistance on the part of the
physicians, there is resistance on the part of the CAM
practitioners, and also the patients tend to
compartmentalize quite a bit, which has already been talked
about.
It also takes a lot of time to do the integration,
and it is not easy to do, particularly in terms of the
managed care plan. When we actually started this, we wanted
to be able to share all our records between the CAM
practitioners and the 14,000 primary care physicians at
Oxford.
We got a strong push-back in focus groups and from
other patient groups, that they didn't want us to share
those records. They didn't want us to tell their primary
care physician that they were seeing the acupuncturist, and
under law, they have the right to do that. The patient's
record belongs to the patient.
If a patient tells us we are not supposed to tell
their internist that they are going to see a massage
therapist or a nutrition counselor, we have no choice. We
cannot create integration. We saw some rather strong push-
back on that when we first created the program, which I
think is another interesting point. Many of us have been
talking about whether or not it is possible to fully
integrate these things.
So I would simply say that, overall, it is
appropriate to create access to the therapies we consider to
be safe, and embrace reimbursement, only for those therapies
which have strong evidence base.
Thank you.
DR. GORDON: Thank you very much.
Anna Silberman.
MS. SILBERMAN: My preference is to present an
example of access and delivery issues that have been solved
by High Mark Blue Cross/Blue Shield in Pittsburgh,
Pennsylvania.
Yesterday, you heard the testimony of Rick
Collins, our medical director for the Dean Ornish Program
out in Nebraska, and Walter Czapliewicz, a patient from
Pittsburgh.
In 1997, High Mark made medical pair history by
becoming the first insurance company in the country to both
provide and pay for the Ornish program for any of our
members who have any of our products absolutely free of
charge, because what we learned is that if heart disease is
just bypass with surgery, without also addressing the
causes, then the problems tend to come back again. That is
why bypass surgeries are often repeated within 10 years, and
angioplasties within six months.
So High Mark decided it would actually be
ethically and financially irresponsible not to offer this
alternative to bypass surgery. Our decision was easy for
two reasons:
Number one, it makes sense for the patient. As
you heard, the Ornish program works, it is the right thing
to do; and number two, it makes good financial sense. It
pays for us to invest in proven alternative therapies to
reduce utilization.
The Ornish program has four components: moderate
aerobic exercise; group social support; a low fat vegetarian
diet, with supplements; and stress management, which
includes meditation, yoga, progressive relaxation, and
guided imagery.
So you see this is truly health care and not just
sick care.
The program is delivered by a team of physicians,
exercise physiologists, registered dieticians, yoga
instructors, behavioral health clinicians, and other
professionals, both alternative and conventional, all
executed by the ninth largest health insurance company in
the country.
The team services patients for 10 hours a week,
helping them to integrate better health practices and self
management into their lives. We also help them develop
meaningful relationships in a supportive and very loving
environment.
It is a very odd thing to see at the corporate
headquarters of a large insurance company, but our senior
management supported the Ornish program because of the
science behind it. It can reverse heart disease, and it
has.
Our patients have 57 percent less angina; 50
percent less depression; cholesterol improved by an average
of 22 points; and body fat by 10 percent. All of these
biometric and psycho-social risk factor improvements are
statistically significant.
I believe you all have a chart in your books with
even more dimensions.
But most importantly, there has not been a single
heart attack or death since 1977, when we implemented this
program. There has been one bypass surgery, one stroke, and
four angioplasties among these 400-plus very high risk
patients.
The point is these cardiac events are far below
what would otherwise be expected with conventional
treatment.
DR. GORDON: Excuse me. Let me interrupt for just
a second. It is Tab J, Roman numeral V, Tab J. Roman
numeral V, Tab J.
MS. SILBERMAN: So we would expect 77 percent of
our patients with this type of risk profile to experience
some type of adverse cardiac event. The Ornish program is
completely safe, there is no risk, there is no downside. So
this alternative is actually very conservative medicine at
its best.
The outcome data challenges the progressive nature
of heart disease and the progressive expense histories for
cardiac clai
MS. Our actuaries agree. They have calculated
savings of $17,000 per patient, which translates into a
little over $8 million in savings.
The preliminary results of our matched control
group study indicate a $297 per member, per month difference
between our treatment and control groups.
So we were able to draw on a lot more than good
intentions here when we decided to start a new company to
roll this out across the country. It is called Lifestyle
Advantage, and the purpose of Lifestyle Advantage is to
change the way or somehow influence the way heart disease is
managed and financed.
In our view, providers and payers must come
together to do what is right and to do what is cost-
effective. You need reimbursement for CAM services to
become permanently ingrained in our health care system.
It is one of the reasons we formed Lifestyle
Advantage. With this union, our new company is well
positioned to increase reimbursement and access by using the
relationships that High Mark already has with other Blue
Cross/Blue Shield plans.
In fact, many have already chosen to reimburse for
the Ornish program, and we have reimbursement codes that are
now available to be used nationally.
In summary, our program is less painful, less
expensive, more effective in the long run. It is one of the
things a health plan can do to be socially and financially
responsible, and for High Mark it gives us a great
opportunity to earn customer respect, trust and genuine
patient satisfaction, build bridges between the alternative
and conventional communities, and I will go into my
recommendations in a few minutes.
But thank you so much for representing our core
values.
DR. GORDON: Thank you very much.
Lori Bielinski.
MS. BIELINSKI: Good morning,
DR. Gordon and
members of the Commission. It is my honor to address you
today regarding access and delivery of complementary and
alternative medicine services.
I will start with some of the background about how
the Washington State Every Category of Provider law is being
implemented since there are great misunderstandings.
Although the law has taken great criticisms, it is
important to note that it is one of the few sections of
Washington's 1993 Health Care Reform Act, part of the act
that was not repealed. It was the most controversial and
most popular reform, and ultimately was let stand by the
U.S. Supreme Court.
The law has taken into account the attempt of
managed health care to save money, as well as giving
patients some access to choice and involvement in their
health care options. This is not in any way a provider law,
nor is it a mandated benefit law. It allows consumers a
choice of the provider who will treat the condition in which
they are seeking care.
There are currently several different coverage
models of CAM services used in Washington State. Neither
the OIC nor any of its collaborative work groups have
recommended a right way of including these benefits. Each
approach has advantages and limitations for various
constituencies.
The first is the dollar cap method, which is a
straightforward benefit that generally applies a maximum
dollar amount given per coverage year for a set range of CAM
services. Acupuncture, massage therapy, and naturopathic
medicine are the most commonly included services under this
model.
CAM benefits may require referral from a primary
care provider and patients must pay necessary co-pays and
deductibles. When the limit has been placed on more than
one profession or all of CAM services, the Office of the
Insurance Commissioner would deny approval of that benefit
limit.
The condition-based model bases benefits on
allowances related to specific clinical diagnoses or
conditions, such as acupuncture for chemical dependency, or
naturopathic care for migraine headaches.
The covered benefit may require specific clinical
regimens to have been followed prior to the referral of CAM
services. An example is requiring a physical therapy
service prior to authorizing massage therapy services.
The condition-based approach is usually requiring
a PCP referral and co-payments and deductibles apply.
The gatekeeper method is frequently employed under
managed care strategies. A unique difference with this
model is that in some cases the naturopathic physician is
eligible to be a primary care provider.
Patients seeking CAM services to be covered under
their insurance benefits need to have a referral from their
PCP, whether that is an MD, DO or ARNP. The benefits are
subject to medical necessity requirements and established by
the insurer that may be determined by the at-risk PCP group
as well.
The open access model is built on strong care
coordination and quality infrastructure, allowing
integration of CAM and conventional practitioners and their
services. Enrollees are allowed access to network providers
of all categories without a PCP referral. In fact, there is
no PCP or gatekeeper required.
The self-referral method allows patients to
directly access all providers and preventive care services
and usually a separate rider.
Although the self-referral approach method does
not usually require a PCP referral, benefits are subject to
medical necessity determinations.
Frequently the self-referral approach may be
implemented in conjunction with a preventive care benefit.
Preventive care benefits are not usually part of the policy,
but can be negotiated by the purchaser.
The discount networks are where some insurers have
begun to negotiate discounts with CAM providers through a
contract of network for their policyholders, in exchange for
being listed in the carriers' approved provider guide.
These carriers do not provide reimbursement for the
enrollees' expenses and costs are paid directly by the
patient.
This is not in compliance with our statute and
rules related to the other category of provider law, since
the patient doesn't actually engage their benefits when
seeking care from CAM providers.
Carriers have the right to set coverage limits,
including services of CAM providers and the OIC rules state
that these limits may not be unreasonable and may not be set
by provider type but can be set by covered services. The
carriers can't exclude a particular category of provider
altogether, nor can it cover certain provider types only by
a separately priced optional benefit.
Reasonable limit has yet to be defined, and the
filed limits by each of the carriers is something currently
under review. A data call related to the criteria used by
insurers to establish limits for health care services is
currently under way by our agency.
After a preliminary review of this data, I can
tell you there is no established pattern of how these limits
are set. In text, I have provided you some of the
preliminary results, but consequently, when carriers
contract with outside entities to provide these panels,
there seems to be a disconnect to the very concept of
integrative medicine.
To close, I will reference a chart I submitted in
advance, outlining the reported coverage that insurers in
Washington State indicate is available to their enrollees.
I would like to point out that there is
conflicting information from many of the carriers regarding
what they file as benefits, what the cost of the benefit is
to them of their purchaser, and what they report in policy
increase as to how they manage the benefit.
I will end there.
Panel Discussion
DR. GORDON: Okay. Well, thank you. We will come
back to you.
All right, we have questions. We will start with
George. Go ahead. And then George.
DR. DeVRIES:
DR. Dillard, first of all, within
the CAM managed care industry, you have certainly earned a
position of respect throughout the country, and we really
appreciate you being here today, and what you have done at
Oxford has been significant.
You have talked about access to some extent. Can
you share with us the degree of success Oxford has had with
the supplemental benefit programs for chiropractic or
acupuncture, I believe, as well as naturopathy, and perhaps
the perception you have of employers' willingness to pay for
the benefits, but then potentially the difference between
member accessing care under those programs versus perhaps
through other systems you have, where members can access CAM
benefits within Oxford?
DR. DILLARD: Sure. There is a lot in that
question.
Our program is the three-tiered program, just to
remind you. We have some standard benefits. We have an
alternative medicine rider, which is available at a group
level for a slight increase in premiums per year. And then
we have a contracted network of providers that is available
at a set rate, the Oxford rate.
We already had a small benefit for chiropractic
when we were building the program. We went to a standard
benefit for chiropractic for all three states we were doing
business in at that time, and we treated the chiropractors
just like other medical specialists. They would require a
referral by a primary care physician, and the primary care
physicians didn't want to manage that benefit. They said we
would be more comfortable if you manage it. We will make
the referral, you manage it, and so we gave them eight
visits before they had to send us a care plan to allow the
majority of the care to pass under the utilization
management threshold. So that is in all three states
standard benefit for chiropractic.
There is also a mandated benefit in Connecticut
for naturopathic services which we treat exactly the same
way as we do chiropractors.
Acupuncture was put into a rider which was sold to
about 60 large groups, medium to large groups, and was
delivered in the same way and managed the same way as the
chiropractic was in terms of an eight-visit limit.
Our recent surveys have shown that the most
popular parts of the program have been chiropractic,
nutrition, massage and acupuncture, probably in that order.
I did supply you with a more recent survey, one that was
done in 1999, and two in 2000, which will give you some of
that raw material.
The question becomes what is access? Is access
something that is paid for? Is it just having a
practitioner available? We felt we were creating access by
having a vetted network of practitioners whom we have looked
at pretty closely, and we felt that that represented a value
added to the member. It is access, it is not reimbursement.
Those are not the same. Of course, they are related.
So I think again the highest area of utilization
was undoubtedly chiropractic. I think massage and nutrition
were somewhere after that, but those were in the contracted
rate program, and that is all in the survey.
I don't know if I answered your question fully.
Was there something I --
DR. DeVRIES: Well, perhaps have you seen in your
survey work that in terms of patient access of care, have
you seen a difference between when services are covered as a
benefit, versus your discount access programs? Are more
members utilizing CAM professions under benefit programs
than under simply discount programs?
DR. DILLARD: Yes. That is a good question. We
do have a discounted network program for chiropractic, which
means they don't have to necessarily get a primary care
physician referral. They can go to a chiropractor and
simply pay the Oxford rate.
We think that the vast majority of utilization has
been through the benefit with the primary care physician
referral. We have not been able to fully capture that data.
We were entering into a comprehensive research contract
with
DR. Eisenberg's group at Harvard in 1997, when we had
the financial challenges that I described, and we had to
cancel that contract, unfortunately. I think we could have
gotten a lot of this kind of interesting data. I am not
sure about all those, George. I mean there are some details
there that I don't have.
DR. DeVRIES: And one other follow-up. Just the
difference in access between when services are direct
access, when there is direct access to the complementary
health care provider versus going through physician
referral, have you seen any differences related to access
there?
DR. DILLARD: The product of alternative medicine
rider was a direct access program. It allowed direct access
without the primary care physician involved.
Again, we have not been fully able to study that,
but we think that that was a fairly popular product, that
people liked that. There are always difficulties with
gatekeepers in conventional utilization. I think a lot of
people are uncomfortable with having to go to their
gatekeeper to go see an obstetrician-gynecologist. It is a
common complaint.
I think there is a strong possibility we could
look at more non-gatekeeper products. But again, there is a
challenge in knowing how to price them.
DR. GORDON: George.
DR. BERNIER: I have a question for Anna
Silberman. Those are really impressive numbers, the $17,000
per participant that you saved, and the win/win situation.
Are you looking forward to using other CAM modalities in
such a terrific way?
MS. SILBERMAN: I have to say that George was one
of the original members of our board of directors before he
moved on to Texas, so I am surprised to see him here after
eight or 10 years.
What we have is a delivery system called Health
Place. We have 17 centers that deliver CAM programs on a
daily basis to about 40,000 people a month. Some of those
services include all of the things that we talked about
today. I think our most popular service is nutrition
counseling, both in a preventive way and for people who have
chronic conditions.
One of the programs that I am especially proud of
is called Hope, and that is a program for osteoporosis. We
have two arms of that, one for people who already have the
diagnosis, and a preventive program for those who do not.
It centers around nutrition, strength training, all kinds of
health promotion modalities. This is really unusual, I
don't think it would be considered CAM, but our building
engineers actually go into the homes of our members who are
at risk for osteoporosis and clean up any hazards that are
there, and install grab bars and so on.
But the bottom line is, is the results of the
program, and since we have implemented that about three and
a half years ago, we haven't had a single fall or fracture.
So it is nice to do these kinds of interventions, but when
it comes back as a cost savings, it really helps it continue
on and grow.
DR. GORDON: Thank you.
Toni.
DR. LOW DOG: Well, that is great. That was
really my fear.
I have questions for everybody, but since I can
only have one, I will ask Lori. When we were up in Seattle,
it was staggering to see what has been done up there and, of
course, we had the benefit of coming in after all this work
had sort of been done.
Now that you have got some of it behind you, do
you have any pearls of wisdom for us and recommendations, or
things that you would have done differently, or better, or
problems, any advice for us that we can take after reviewing
all this material and spending that weekend in Seattle?
MS. BIELINSKI: I think the significant thing from
my perspective is that I always get confused when I have to
explain the law to somebody. It is baffling to me how many
times I explain it to the same person and they still think
it is a mandated benefit law, and that it doesn't honor
managed care. So the one thing I would say is keep reading
the explanations I have given you because even the only
cost-benefit analysis that I have seen on CAM services from
Milliman Robertson, which is one of the more significant
actuarial firms, still declared our law a mandated benefit
law, which is the only reason it got through the Ninth
Circuit Court of Appeals, is because it is not a mandated
benefit.
So in each state where there are various laws, pay
very close attention to that.
The other side of it is where the independent
networks have a relationship with the Office of the
Insurance Commissioner and the carriers that we regulate.
The Office of the Insurance Commissioner in some states is
elected, some it is appointed, and it is about a 50-50
split.
For our agency, we are elected, and so we have a
very consumer advocacy role for the consumers, as well as
how we work with all the entities that we regulate. We
don't regulate the networks, the primary care organizations,
the CAM services networks, and when there are relationships
established between the independent networks that we don't
regulate and the carriers that we do regulate, sometimes
there are problems with how the independent contracted
entity, for lack of a better term, is going to treat the
providers that fall under various regulations that we do
have. And significantly, right now in our state, there is
one contracted network for CAM services that has obtained
the contract with the largest carrier in the state. They
haven't completed that relationship, yet they are contacting
and discussing and contracting with providers. It has
consumed nine weeks of my time, just on that one issue. It
is a huge problem. The contracts for the providers are
regulated by our agency, yet we haven't seen it because the
carrier and the network haven't finished their relationship.
The carrier would have to file that contract with our
agency.
So they are disbursing a contract that has not
been approved by the agency that they use in a different
state, with different laws, and the providers are -- I have
2000 complaint letters in my office right now that I have to
respond to. So I would say, to summarize my point, have the
carriers and the networks complete their relationship first.
Think about what you are doing to the providers in the
context of continuity of care. Every single patient that
these providers are seeing is going to be affected if their
provider is included in the new network or cut out. This
particular network will cut the chiropractors and massage
therapists current network in half, at least. So patients
that are seen by half of those networks are going to lose
their doctors. Open enrollment for the largest self-insured
entity just closed November 30th, so you can imagine the
ripple effect of what is going to happen.
DR. GORDON: Veronica?
DR. GUTIERREZ: Thank you.
My question was on the same subject, so unless you
would like to expand on any time remaining on the
discussion, I am fine, thank you.
MS. BIELINSKI: I think that is enough said.
DR. GORDON: Wayne.
DR. JONAS: I had a question for
MS. Silberman.
In answering your first question, why and how did you select
the Ornish program, you described the data and that type of
stuff, which is great. I am wondering, were there any
individuals who were in the management hierarchy of Blue
Cross that have had personal experience with the Ornish
program?
MS. SILBERMAN: In this case, no. In some of our
other sites across the country, there are 12 of them, that
is true. In the case of High Mark Blue Cross/Blue Shield,
no, there hadn't been anybody at that point in time. Once
we implemented the program, some of our executives took
advantage of it, for both themselves and their family
members. It was simply a matter of, you know, I heard
DR.
Ornish speak at a conference, and to me it made good sense,
and they received it very well.
DR. JONAS: So you brought it to them, then?
MS. SILBERMAN: Yes, I did. There were a number
of skeptics, of course, internally who -- you know, they
called me Anna Alternative and all kinds of things like
that, so we had our share of those folks who were asking me
if my VW bus was outside. There were a lot of skeptics who
are the very same people who are now attending our program.
DR. GORDON: Tom, and then George.
MR. CHAPPELL: James, I am just wondering about
the economic sustainability of your approach to this, and
whether you envision this becoming a highly profitable and
sustainable approach for your company.
DR. DILLARD: It is a good question. I don't
think that Oxford approached this from the viewpoint --
MR. CHAPPELL: I heard you say that, but I am
wondering whether you envision -- is this ready for
commercial profits, as well as social profits at this point?
DR. DILLARD: I don't know specifically what our
ROI would be. It has not been fully calculated. I wish I
could give you that information. The perception has been
that this has been a pretty low cost program to roll out
inside a managed care company.
The fact is that during 1997, the company grew
from 1.4 million members to over 2 million, almost 2.2
million members, with the alternative medicine program as
one of the major pieces of its marketing and public
relations. It was considered to be a very successful
program for this reason.
How to interpret that and place that into
profitability, the company was doing very, very well at that
point. The 52-week was 89, and after we had a rather bad
projected earnings in October 27th of 1997, it went down to
a 52-week low of six, which had actually nothing to do with
the alternative medicine program. I really want to make
that clear because a lot of people think about the Oxford
program, they go, hmmm, interesting program, alternative
medicine, tanked the company. Not true.
I think we still see it, not necessarily directly
in the revenue stream, but something that lends a lot to the
brand, and is considered to be still by our operating
officers as being a major part of the Oxford brand.
DR. GORDON: George, and then Joe.
DR. DeVRIES: Lori, could you help the Commission
maybe understand how the Department of Insurance in
Washington looks at -- and I am thinking of your regulatory
requirements related to access to CAM providers, and how you
look at that to comparison to medical providers, whether it
be access ratios, providers to total number of patients, or
members, or access in terms of geographic distance, how you
look at access?
MS. BIELINSKI: Sure. Let me start first with the
carriers set their own network adequacy requirements based
on their enrollment and the geographic location of the
majority of their enrollment. They have to file that
standard with our agency. We don't have a formula and
statute or a rule, but I understand that it is probable, and
I am sure there is some drafting currently going on, we are
in a transition situation with a new commissioner, so some
of this will be delayed. But there have been significant
complaints filed by consumers about lack of access, and the
one thing I will say in Washington is CAM is not really
differentiated with conventional medicine any more. It is
just do you have access to your providers, are they primary
or specialty, and specialty includes cardiologists and
massage therapists. So that is where we come from in our
mindset.
The network adequacy requirements are generally
one per thousand. I did just a review of this in terms of
how carriers are setting limits on specifically CAM
services, but all services, and the survey included all
types of providers. So it is one per thousand members in a
geographic location, usually broken down by zip code. The
ratio or the requirement for driving distance usually is
eight miles in a metropolitan area, 15 miles in a suburban
area, and 60 miles in a rural area, which in some of our
rural communities, it sounds like a long way, but it is not.
So that is generally the amount. The part where
it gets to be confusing is when they set an arbitrary limit.
I heard James Dillard mention eight visits. That, in our
agency, is considered arbitrary, so we are undergoing a
review right now of again CAM and conventional services
based on primary versus specialty, and how you set any
limit, or what criteria, standards, guidelines are you
using, and cite the most significant reference for all of
it. What conditions are you limiting? How are you limiting
it, and why? Why do the chiropractors want 22 visits a year
to treat X number of conditions, versus the carriers wanting
to pay for eight a year? What makes one less arbitrary than
the other is where we are trying to get to.
Summarily I can tell you in a brief review of this
that I did on the plane, there is no pattern, and it is very
arbitrary, and I am not sure what anybody is going to do
about it. So if I were to leave you with a second
recommendation, I would say find out what the criteria, what
is the most common guideline used for any medical necessity
definition to setting a limit on anything? Because
otherwise the carriers could be allowed to sell what is
considered in our world an illusory benefit. Six visits to
a chiropractor a year doesn't treat most conditions I am
aware of, and thank goodness for my medical background.
DR. DILLARD: If I can just clarify the one point.
The eight-visit limit is not the visit limits. That is the
point at which we ask for any information from the provider.
That is when utilization starts, and that was based upon
numbers that came from the Canadian report published by
Pramanga, and I can give you the citations I am referring
to.
MS. BIELINSKI: I wasn't trying to pick a fight.
[Laughter.]
DR. GORDON: Wayne.
DR. JONAS: It is a related question, actually. I
wanted to ask
DR. Dillard a little bit about how you
establish the benefit package which you have sort of begun
to answer, but ask you about the appeals process and whether
you have had problems with "overutilization" and, if so, how
do you deal with it, what kind of mechanisms are in place to
address the appeals process?
DR. DILLARD: Well, that is a huge topic. The
benefits that we decided to go with -- first of all, we took
six provider types from a survey, those were the ones that
our members were already using, they were the most popular
provider types, not rocket science. We went with mandated
benefits. We knew that there was going to be a mandated
benefit coming down, and instead of New York, we decided to
be proactively involved with that. We actually had some
input into the writing of that bill. Proactively, before
that bill came out with benefits that were fully in
compliance with the Insurance Equality Act, it was signed by
George Petaki.
In terms of the appeal process, this is all a
peer-based appeals process. I didn't know any other way to
do this. The programs were structured using peer advisory
boards, and the appeals process was by using practicing
acupuncturists and chiropractors and naturopaths in the
community, to look at this care and say what is reasonable,
what is falling outside of reasonable standards of care,
looking at documentation, is the patient getting any better.
We used really mechanisms with very similar conventional
utilization.
DR. FINS: These were external reviews, though?
DR. DILLARD: No, they were internal.
DR. FINS: They were internal.
DR. DILLARD: Yes. We hired expertise from the
community.
DR. FINS: So you have a conflict of interest,
presumably? The people who are reviewing are on the Oxford
payroll in some way or another?
DR. DILLARD: That is correct.
DR. FINS: Has that been satisfactory to your
membership, as far as the appeal process?
DR. DILLARD: Our statistics tend to indicate that
the majority of the network is pretty happy with what we do.
We are considered to be the most generous payer in the Mid-
Atlantic, by the way, and I think they haven't had too much
of a problem. We have maybe 5 percent of the network, maybe
10 percent, that we consider to be somewhat of a problem.
We are doing the provider profiling on that right now, and
we will be looking much more closely at those practitioners
to see the people who are trying to go up to 48 visits for a
year, 52, 76, and look at those providers more specifically.
But it has all been based upon peer review.
DR. GORDON: Any other questions before we close
this panel?
MR. CHAPPELL: I think I have one more financial
question. Do you have any sense of the relationship of
income from CAM services versus all other services is?
DR. DILLARD: The income from our CAM program
specifically?
MR. CHAPPELL: Yes. I haven't quite asked it the
way I wanted to.
Can you tell me what share of reimbursement is
going for CAM services versus non-CAM services?
DR. DILLARD: I know what our costs per member per
month would be, and they are fairly in line with standard
numbers that you are going to hear on the Atlantic Coast.
Let me make one thing clear. We did not raise our
rates because we built this program. There was no cost that
was passed on directly.
MR. CHAPPELL: Yes, I read that, James. Let me
just repeat the question. Maybe I am not asking it right.
What share of your reimbursement is going to CAM
practitioners versus non-CAM practitioners?
DR. DILLARD: The percentages, I don't know off
the top of my head. I could probably get that data for you.
MR. CHAPPELL: It would be very helpful because
that is such a valued model. I mean is it less than 5
percent, is it --
DR. DILLARD: I would estimate that it is less
than 5 percent. We have the big ticket items that all of
the managed care companies have, the maternity care, the
typical things that you see.
MR. CHAPPELL: I am trying to get a feel for how
big a question we are asking for here, if we want to
integrate reimbursement in existing management.
DR. DILLARD: Oh, yes, it is a critical issue. I
can share with you what our PMPMs, and I can try to get some
ratios with our conventional costs, if that would be
helpful.
MR. CHAPPELL: That really would be great.
DR. DILLARD: Okay.
MR. CHAPPELL: Thank you.
DR. GORDON: I want to thank you all. One of the
things I am realizing as I am sitting here is the wonderful
collegial spirit that we feel with the three of you, and as
well as with other presenters, and in line with Tom's
request, I am wondering if all of you would help us even
more with the next stage, by telling us what is working and
what is not with what you are doing, because you all have
exemplary progra
MS.
So, with the Insurance Commissioner's Office,
Lori, should this be a model standard? And if so, why? And
if not, where should it improved? And similarly with each
of you. I think that will be a long way to helping us as we
make our decisions later on.
Thank you very much. We will take five minutes,
and only five, and then we will come back.
DR. GORDON: This panel, which we welcome now, is
somewhat different from the other panels in that what we
have been talking about earlier in bringing in some of those
who have developed innovative services is integration, and
we asked these three presenters to come to talk with us
about models that are really fundamentally based on other
systems of health care, other healing traditions other than
Western medicine, although they may be studied or examined
or understood in Western medical terms as well.
So I am very happy to invite the three of you to
come to present to us.
Our first presenter will be
DR. Robert Schneider.
DR. SCHNEIDER: Thank you,
MR. Chairman, and
members of the Commission.
I think everyone here is aware of the recent
survey in JAMA which reported that 40 percent of the
American population, or nearly 100 million people, not only
use CAM services, but in addition, and not necessarily the
same people, suffer from one or more chronic disorders.
This is despite this country having the most advanced health
care system in the world.
Therefore, it is clear, since half of our people
have chronic diseases, that a new, more effective approach
or complement to our conventional health care system is
needed.
Ayurveda, the topic of my discussion this morning,
is part of a larger, more complete system of natural
medicine derived from the ancient Veda tradition of India.
This is called Vedic medicine, or the more recent
restoration of this system, including the range of
diagnostic and therapeutic approaches has been called
Maharishi Vedic medicine which includes 40 approaches for
dealing with influences of health, from levels of mind,
physiology, behavior, the near environment, the distant
environment, and even the public environment or public
health perspectives.
Over the past 30 years, there have been about 600
published scientific studies on the effectiveness of Vedic
medicine approaches for the prevention and treatment of
disease. These have been conducted at more than 100
independent institutions in more than 30 countries around
the world.
These include a series of randomized control
trials conducted by our group and others sponsored by the
National Institutes of Health on the effects of Vedic
medicine approaches on prevention and treatment of
cardiovascular disease.
Reprints of these studies and review of literature
is included in your Section K of your notebook, and in the
reprints handed out this morning.
But briefly, the clinical syndromes that have
shown to be most responsive by control of clinic research to
these various approaches of Vedic medicine, which include
meditation, herbal approaches, diet, purification therapies,
behavioral approaches, even the influences of architecture
in an environment, include first cardiovascular disease, its
risk factors, hypertension, smoking, psycho-social stress,
high levels of oxidized lipids, cardiovascular morbidity,
cardiovascular mortality, and related health costs.
The second area, which has shown considerable
effects are psychological disorders, depression, anxiety,
and related behavioral disorders, such as substance abuse.
There is preliminary evidence on cancer prevention and
treatment in terms of quality of life improvements, as well
as potentially on mortality rates.
Chronic pain has been very responsive. Age-
related disorders in mood, physical function, cognitive
function, and quality of life have been responsive in a
range of primary care disorders, or disorders commonly seen
in primary care, such as insomnia, digestive disorders,
chronic fatigue, and women's reproductive disorders,
menstrual and menopausal sympto
MS.
Second, in terms of cost effectiveness, several
studies, which are reviewed in your handout and in your
reprints, have reported 50 to 80 percent reductions in
health care utilization and related health care costs, with
the approach of transcendental meditation, part of Vedic
medicine, and other Vedic medicine approaches. This has
been true for both in-patient and out-patient utilization.
Patient satisfaction is reflected in relatively
high compliance rates with these modalities which in
published reports have ranged from 80 to 97 percent
regularity with these recommendations, which contrasts with
modern recommendations, with compliance with modern
pharmacotherapy, which is 33 to 50 percent, at least for
anti-hypertensive regimens. So roughly twice as great.
Based on these data, we have three main policy
recommendations for this commission.
One, regarding access, it is largely, although not
exclusively, based on reimbursement policies. Therefore, we
recommend that this Commission further recommend that
natural medicine services, in this case Vedic medicine
services that are shown to be effective and cost-effective
in published, peer-reviewed scientific research, be
reimbursed by third-party payers, including government
payers, such as Medicare and Medicaid, and even
recommendations for private reimbursers.
Second, regarding delivery of services, this is
largely determined by availability of qualified
practitioners and their legal ability to practice in their
respective area. In this domain, we recommend a two-stage
process related to practice by qualified practitioners, to
be phased in over a five-year period.
First, that certified practitioners be allowed to
practice in their areas, following the Minnesota model
currently. Certified practitioners will be those who have
successfully completed an approved course of study at a
recognized and accredited institution of higher learning,
and second, who are certified by national professional award
in their field.
Second, we recommend that over time states adopt a
licensure procedure for natural medicine practitioners,
including Vedic medicine practitioners, and licensure would
be dependent on certification and completion of other state
licensing requirements, such as an exam or experience
requirements.
Thirdly, in terms of delivery of services, this
largely dependent on a continued stream or training of
qualified practitioners. Therefore, in the area of
education, we recommend that the Commission further
recommend to the federal government the granting of grants,
the provision of grants by the government, not for research
as NCAM does, but in this case, grants to educational
institutions of higher learning for the training of natural
medicine practitioners, in particular, Vedic medicine
practitioners. These institutions would be recognized in
their field and also accredited by standard accrediting
associations.
In further consideration of delivery, whether it
be within the exclusive framework on integrated with
conventional health care delivery systems, my colleagues and
I actually recommend both approaches.
For example, there is now a series of maharishi
Vedic medical centers being constructed in each
Congressional district in this country, several of which are
already up and running, which are examples of focus,
providing natural medicine services within the community,
and also within integrated health care services.
In conclusion, Vedic medicine, including Ayurveda,
but not limited to Ayurveda, much expanded beyond aruyveda,
has been shown by extensive scientific research to be
clinically effective and cost-effective.
DR. GORDON: I think we will come back and we will
have some very specific questions about the inclusion of
that provision of services. Thank you. Sorry to cut you
off, but we have gone well over time.
DR. SCHNEIDER: Thank you.
DR. GORDON: Next will be
DR. Tori Hudson.
DR. HUDSON: Thank you,
DR. Gordon. Thank you for
the invitation and the opportunity to be here today, and I
really appreciate you including the voice of naturopathic
physicians and attention to women's health, in particular.
I usually start my lectures and presentations with
a joke, but it cost me too much time. So I am open to
solicitation later.
Essentially, naturopathic physicians are licensed
primary care family physicians with a specialty in natural
medicine. We utilize nutrition and lifestyle counseling.
We prescribe nutritional supplements, plant extracts, and
other natural therapeutic substances and techniques, as well
as selected pharmaceuticals.
The seven principles of naturopathic medicine and
the two additional integrative principles, as I discussed in
my written testimony, could actually serve as the
cornerstone of a new medical model, one that many of us are
calling integrative medicine. But we must be careful, I
think, to define integrative medicine, because if we do it
right, it actually has a potential to fundamentally
transform the quality of health care, the accessibility of
health care, the cost of health care, and therefore the
health and quality of life of our communities.
My vision of integrative medicine is basically a
cadre of health care disciplines and practitioners, each
with their own scope of practice, each with their own tools
of their trade, but also each with a common understanding, a
common respect, and a shared commitment to coordinate care,
cross-refer, and co-manage patients.
The federal government could go a long way towards
providing a framework in which all of this can take place.
The framework, however, must impact the psychological, the
cultural, the political, financial and logistical
limitations and biases that currently exist.
As it is now, the conventional model has
monopolized and dominated medical education, medical
research, medical reimbursement, and medical practice in
this country, and remarkably, there are other medical
approaches that are most often safer, often less expensive,
and usually effective, but not always, in handling about 90
percent acute and chronic health care proble
MS.
In women's health, an integrative medical
framework from the top to the bottom of the system could
actually bring us reliable treatments for very little
understood and very poorly treated conditions, such as
interstitial cystitis and vulvodinia, and fibromyalgia. It
could bring attention to the extensive scientific data on
the prevention of breast cancer with soy and fiber and fish
oils and green tea, or the proven successful alternative
treatments for cervical dysplasias. It could study outcomes
of breast cancer patients who receive both conventional and
alternative treatments.
Much more common is the issue of menopause. By
the year 2015, 50 percent of the U.S. female population will
be menopausal. I will let you pause there, just to
contemplate that.
[Laughter.]
DR. HUDSON: What conventional medicine dominantly
has to offer those women is that all women should take a
prescription, hormone replacement therapy, that might lower
their risk of heart disease, while at the same time
definitively increase their risk of breast cancer.
Why routinely use a drug that poses an increased
risk of one disease to all, while decreasing the risk of
another to only some?
An integrative model would better identify
individual risk factors for individual patients, not a one-
size-fits-all approach, but individual assessment with an
individualized treatment approach.
Imagine intentional, structural, collegial,
coordinated health care clinics and hospitals and research
centers across the country, with MD, DC, DO, Ph.D., LAC,
LMT, Ph.D., and all other allied practitioners working
together to provide the best that each has to offer in the
co-management of issues like osteoporosis and heart disease
and breast cancer. But also a very common, every-day
women's problem such as PMS and fibrocystic breasts, pelvic
infections, menopause, endometriosis, and uterine fibroids.
To me, integrative medicine is about maximizing
the strengths of each discipline, while minimizing the
weaknesses of each, so that we can have the best possible
outcome for the patient.
Women want their practitioners to work together.
This can be seen in survey after survey. Women are hungry
for education about their options. They are hungry for
respect of their choices by their health care practitioners,
and they are hungry for communication and coordination
between their practitioners.
Women, I would assert, are not only seeking this
kind of coordinated, integrative health care, but the female
patient, in my opinion, is actually making it happen,
especially in the menopausal woman. Eighty to 90 percent of
menopausal women who are prescribed hormone replacement
therapy discontinue their hormone replacement therapy within
the first year of use, and they seek alternatives, in many
cases, and others receive no treatment at all, but they are
especially engaging in a fairly complicated educational
process of deciding when to use HRT, when to use botanicals,
when to use supplements, and when to use a combination of
those things.
My experience in Portland, Oregon is one of having
a women's integrative clinic with ND, MD, DC,
acupuncturists, massage therapists and counselor working
together, referring back and forth, discussing the co-
management of shared patients. In my community we have a
naturopathic medical school, a conventional medical school,
a chiropractic college, an acupuncture college, two massage
schools, and three schools of nursing. We have many
examples in integration: costs or discipline
preceptorships; and individual physician offices. We have
referrals amongst all disciplines. We have joint research
studies between the conventional medical school and the
naturopathic medical school. We have integrative medical
meetings, and continuing medical education into several
integrative clinics, shared adjunctive faculty appointments,
residency exchanges, and an integrative medicine residency.
It appears obvious that the time has come for this
concept of a team approach to health and well being, rather
a multi-disciplined, truly integrative, safe, effective,
affordable system of health care that respects the choices
of individuals, the wisdom of many minds, and the spectrum
of all that nature and humans have to offer.
Thank you.
DR. GORDON: Thank you very much, Tori.
Next is Robert Duggan. Bob, good morning.
MR. DUGGAN: Thank you. I am honored to be here
and have a moment to speak with you. You have a written
paper. I am going to make a few comments off of that.
First of all, I would like to say that I have been
practicing acupuncture for 30 years. I am the president of
a school with 220 graduate students. We have 700 graduates
across the country. Eighty-four percent of our graduates 10
years later are earning good incomes and higher than the
national average for acupuncturists, and among our
graduates, not a single graduate has ever defaulted on a
federal student loan.
I say that by way of credential. I am not here
speaking on behalf of the acupuncture profession, but rather
on behalf of some issues that confront acupuncturists,
acupuncture practitioners and acupuncture schools.
The first critical issue is that our students are
trained not only in the modality of acupuncture, the skill
of acupuncture, but in the art of healing. I think there is
a conversation to be had that all of CAM and perhaps all of
medicine in the country at the moment, is divided between
modalities looked at in a reductionist mode, and the context
of that modality within the art of healing or culture of
healing.
We have done studies that indicate patients keep
looking for that art of healing, and then their satisfaction
rate increases, and I can give you the reference to that.
Your questions to me were about integration of
acupuncture in mainstream and complementary medicine,
integration of acupuncture with herbs, with the other parts
of Oriental medicine, and the simple position that we have
taken at the institute in Columbia, Maryland for 25 years is
great diversity. Our graduates practice in an enormous
range of situations, in hospitals, in private practice, and
there should be just a fostering of enormous diversity.
It takes 10 years to be a good acupuncturist. You
can learn various skills, but that is one of the major
things, and we have had a clear policy through those years
of avoiding turf battles and been very conscious of that.
One of the major -- and I suppose these are some
of the policy implications that come out of our work over
these years
-- is when the conversation is who is the primary care
provider, the patient is the primary care provider. The
patient is the primary care provider. We will only shift
the cost, quality, access dilemma in American health care
when we understand that by making the patient the primary
health care provider, we will move 70 percent of the visits
out of the sick care system into a wellness culture. We
know that is critical to the success of our acupuncturists.
We know that the ones who see themselves as educators of
the empowerment of the patient do better than those that are
simply delivering a modality.
I think we need to consider the economics. My
graduates, our graduates, are being socialized into a
reimbursement model that favors the modality over the
healing art of the individual patient. We have one program
we do with a corporation where the practitioner guarantees
free treatment after a certain point if the patient hasn't
taken on their own quality of care.
Some other specifics that you might recommend,
that all schools of medicine, complementary or mainstream,
foster relationship-centered care, built on the
recommendations for mainstream medical schools, and take
that into all the complementary schools.
Second, that there be a separate agency
established to deal with the issue of the quality of herbs.
We are well aware in traditional Chinese medicine of those
issues, and the usual way of looking at it, which is not the
same economics, not the same philosophy, that there be a
separate and distinct agency. An issue that has come up
locally in Maryland is in using some of the tobacco
settlement money to encourage the use of the lands now
devoted to tobacco growing for the growing of herbal
products, high quality herbal products, and organic foods.
There is a bill in Congress at the moment on the
student loan repayment program to induce practitioners of
complementary care to work in a city and areas of economic
need. I think that is a bill that should be fostered, and
anything that pushes the CAM providers in the direction of
doing pro bono work should be supported in the community.
I think CAM and wellness education from the first
grade onward is an important outcome. I spend most of my
clinical day educating people into simple realities that
they should have learned in the grade school, and I think
that is a background. The present licensing systems in most
states for acupuncture forces the schools to devote all
their time to technique and specific knowledge-based, rather
than relationship-based educational-based learning.
I think there is a policy that should move some of
the research that is being done so that the research
outcomes translate across into clinical practice. It is one
thing to see the research outcomes. I rarely, in my
clinical practice, experience that those research things are
known in the local physician's office or the other CAM
providers.
I think that research on quality of life outcomes,
rather than on mechanisms, should be fostered. There is an
enormous expenditure trying to understand the mechanism of
acupuncture or of an herb, and we know very little about the
overall quality of life outcome. We have for 25 years at
the institute refused to do clinical studies because we knew
that patients were asking the question, my asthma has become
my teacher. It is not that my asthma goes away, my symptom
has become my teacher. So we ask the wrong question in
research.
There are other policy things that I have put in
the papers. I would leave it there, and I am happy to take
your questions.
Panel Discussion
DR. GORDON: Great. Thank you. Thank you all
three.
There are obviously a tremendous range of issues
on which each of the speakers can comment. I would like for
us to focus pretty intensively on delivery of services in
our questions. We can always ask them other questions
afterwards, or indeed ask them to come back and sit on other
panels.
So if we could begin, please.
DR. TIAN: I have a question for Professor Duggan.
I admire your work and your institution has done a lot in
developing acupuncture in Oriental medicine.
Regarding delivery of service, regarding the
herbal remedies, as I understand you to state, that the
federal government stopped regulating, and do you think that
should be handed to care by CAM providers because herbs can
be divided into therapeutic and nutritional. If I try to
use this to divide it into two. So how do we do that, in
your opinion?
MR. DUGGAN: I think we have to start in the grade
school, with individuals relearning their relationship to
plants and nature. So you start from food and you begin to
move from food to plants, and then you define the line where
you have some very highly specialized folks who know a great
deal about specific herbs.
I think we start that conversation in the wrong
place by turning plants into products, and we have just been
approved to start a three-year graduate degree program that
will address these issues, both for Eastern herbs and
Western herbs. But to recover that plants are part of the
ways that we learn to heal itself, and that all the foods we
eat are plants.
What we have done in this culture in a
reductionist way is turn the plant into a product where we
are looking for the active ingredient. That is not the
culture of the medicine that I learned. It is the culture
that the medicine I know about is being socialized into. So
the policy issue would be how do you restore an awareness of
plants as healing and then begin to define where is that
line between what is food, what is part of every-day grade
school, high school learning, and what must be
professionalized. And I think we are just beginning to
explore it.
DR. TIAN: By the way, regarding the quality
control of the herbal product, at the national level or at
the state level, how can we do that? Because there is no
such organization or like a consumer report.
MR. DUGGAN: That is why I recommend it. I think
there needs to be a separate agency so the questions are
addressed differently, because there is a major, major issue
here of both the quality of the products, whether the
products are properly labeled, all of those issues.
Ideally, the industry would take it on itself, and there
needs to be an agency that will support that. It is a major
issue in Chinese medicine.
DR. FINS: Bob, I don't want to sound redundant,
but this is the fourth time I have asked this. I agree
completely with the two major points you made of first
empowering the patient, and how important that is, and I
never realized this until I was a patient. I mean as a
physician, we can pay lip service to it, but I never
realized. I think that is extremely important and one of
the major reasons for use of CAM.
The second thing is education, and as I brought up
before, I just have the feeling that we are failing in
education for lifestyle changes. I know, and you know more
than I do, that there are a number of private organizations.
Ernest Winner of the American Health Foundation was a major
proponent of going into schools and giving education, and
yet somehow it doesn't translate into lifestyle changes in
the adults.
So I am going to ask you specifically should this
Commission be even considering the step of asking our
legislators to mandate that there be classes in nutrition
and lifestyle, wellness living, in all schools? I mean
should that be part of a national education policy? How do
we do this?
MR. DUGGAN: Absolutely. Absolutely. It has to
start from the first grade, and it has to start with
awareness of breathing, of drinking, of sleeping, of eating.
The clinical experience that came to me the other day,
talking about women's medicine, a woman brought me in a pile
of clinical reports from the best medical centers in this
country and from every one of the notable CAM providers in
this country, a report. She had a series of vague sympto
MS.
It was 2:00 in the afternoon, and this was a highly
educated, highly successful, wealthy woman who could afford
that stack of reports, and it was 2:00 in the afternoon, and
I realize you have been sitting here working hard all
morning, and I don't know how healthy the schedule is, and I
said what have you eaten? She said a cup of coffee at 7:00
this morning. What did you eat last night? Hamburger.
When did you last get some exercise? Three weeks ago.
After a while I said do these symptoms ever go
away? A long pause. When I went on vacation in Canada,
they went away.
So, yes, absolutely. And I think insurance must
de-incentivize the providers from covering that stack of
reports, without asking the basic home-grown question, are
you taking care of yourself?
DR. FINS: Well, I am just trying to think of some
specific question. On my automobile insurance, if you take
a course -- in my case, my wife takes the course for both of
us, I don't know that works, but --
[Laughter.]
DR. FINS: But anyhow, she takes the course and we
get a 10 percent reduction on the insurance.
MR. DUGGAN: Same thing. Absolutely.
DR. FINS: Do you advocate things like taking a
course in wellness --
MR. DUGGAN: Absolutely.
DR. FINS: -- and then there would be a reduction
in your health care policy. It would have to be a
government plan or something.
MR. DUGGAN: But you have to watch cherry-picking.
You wind up getting only the educated that lower rates, and
that transfers the rates. That is why I think you need a
whole session just on the economics because graduates of our
school are being socialized into an economics that doesn't
serve what they are trained to do. And you are absolutely
right, that is a very complex issue, Bill, and it should
start from the first grade, though, and you should mandate
that there be wellness, and I don't mean prevention, because
we are not talking about 30 year out prevention, we are
talking about the sense of wellness today so it is an
immediate, same-day return on investment.
I know from my food that I am getting back and I
feel better. I play better football in high school. All of
that should be integrated. But this cannot start with the
50 year old who is then in trouble.
DR. GORDON: Just one more question.
DR. FINS: But I guess, to be more precise, I am
saying my perception, and I could be wrong, is that the
current policies are not effective enough. Do we need to
look at more innovative policies and maybe more legislation?
I am not a great fan of overwriting federal legislation,
but is this a case where we need to recommend some mandates
in educational procedures?
MR. DUGGAN: I think to get it started, there are
going to have to be some incentives to make it move, because
my experience is the institutions will keep doing what they
are doing, unless there is some leverage forced into them,
to have them do it differently. So you have got to find
those tiny leverage points that push in the awareness of
Ayurveda and naturopathy in the second grade.
Why should I have a child saying to a nurse I know
about the pulses, and starts to tell the nurse about the 12
pulses, and the nurse goes quiet, because this child has
grown up with Chinese medicine. And when the nurse is
reading the blood pulse in school in the third grade, the
child says, oh, I know all about the pulses. And the nurse
doesn't know what the child is talking about.
We now get a significant number of, I think it is
20 percent of the new entrants to our graduate degree
program each year, come straight out of college because they
have never in any significant way experienced allopathic
medicine. They have been treated by herbs and acupuncture
since birth. They come straight in to school, they have no
awareness, the thought doesn't cross their mind. You are
absolutely right, though.
DR. GORDON: Tierney?
DR. LOW DOG: This sort of dovetails because I
agree very much about where the culture of plants comes
from, and all of the products that are driven today actually
come from traditions that use them, and ointments, unguents,
teas in very simple for
MS.
My question would go to any of you about products,
because if we are talking about access and delivery, part of
that has to be about the delivery of product. I know that
many CAM practitioners make a significant amount of their
income from the sale of products, and many companies
actually specialize in just providing products that can only
be purchased through a provider that you can't just go and
get at the health food store.
Does that affect delivery of those products? Is
there any concern about that? I would just like to hear
some comments on that since we are talking about access and
delivery, and if you are restricting access, or you are
basically funneling people through, saying the only product
you can get is from me, you can't get it through the health
food store, how does that affect this whole dialogue of
access and delivery? Anybody?
DR. HUDSON: Well, one of the -- I think there is
the medical aspects of your question, and then there is, I
think, conflict of interest aspects of your question.
In terms of the conflict of interest, yes, I think
there is a conflict of interest when you provide and sell
products, you recommend products that you sell out of your
office. And naturopathic physicians do that. But I would
also point out dermatologists, ophthalmologists,
optometrists do that, and probably others that I'm not aware
of. An OB-GYN who recommends a pelvic surgery that they
then perform is also potentially a conflict of interest. So
I think there is a conflict of interest, and I think that
right now we are sort of relying on an honor system, and
maybe as more money is involved and companies like Phillip
Morris own Boca Burgers and other things, that maybe we will
have to attend to this in something other than just an honor
system.
The medical aspect is that there are herbs and
nutrients and doses of herbs and nutrients that people
should not be prescribing for themselves, or taking
themselves, as you well know.
I might treat a woman even with something as
simple as PMS and I recommend a certain combination of
ingredients, and she will say, oh, I already tried Chase
Tree or I already tried Natural Progesterone, and then I
will clarify, well, what dose did you really use, and for
how long did you really use it? And clearly she was
undertreating herself, and merely just doing the same items
in a different pattern, in a different frequency, in a
different strength, yields completely different results.
The health food store aisle medicine is different
than medicine delivered by a knowledgeable practitioner, and
I think the consumers themselves are at the moment kind of
determining, well, when do I want to try this myself, and
when do I want to go to a practitioner? And that is really
kind of an individual choice issue, which I think at the
moment is okay to leave it that way, the individual choice.
They would get better results, often, if they didn't just
aisle medicine, natural food store aisle medicine.
But I think just as we educate people better and
better and better, it will become clear. That is one of the
things I tried to do in my book was have a section, when
should you see a licensed health care practitioner. Not
when should you see an MD, but when should you see a
licensed practitioner.
Well, when your bleeding gets to be this way and
that way, and your pain gets to be this way and that way,
that is when you should not be using the things in this
book, and go talk to someone. I think just education will
help go a long way towards making those distinctions.
DR. SCHNEIDER: In the field of Vedic medicine, I
would say there are three levels: One is lifestyle; second,
is over-the-counter products; and third, would be
professionally recommended products.
The first, which is probably the most important,
is the area of lifestyle, that is diet and daily routine are
very important to prevention and maintenance of well being,
and those don't require a doctor's prescription, but they do
require education from the ground up. At our university, by
the way, there is a primary and secondary school where all
the children from age five years to 18 years meditate
together twice a day, and also have other aspects of healthy
lifestyle, and they are much more healthy and productive in
their school than comparison children. So that is the
first, lifestyle, which is free, and doesn't require a
professional intervention, and it is not a profit center for
anyone other than the grocery store owner, which knowledge
everyone should have from the ground up.
Second, in the field of Vedic medicine, there are
over-the-counter products available where people can make
their own choices according to their own knowledge, and
hopefully they have had some basic education, and those are
products that can be used by the general public and, as Tori
mentioned, are in combinations that are useful for the
public.
The third level, there are combinations and items
in Vedic medicine as in other traditions that do require a
high level of expertise to use, and when used properly, they
are very effective and without harmful side effects.
So I think one has to have that third level.
Whether or not a practitioner sells those himself or
herself, or whether that is a separate dispensary, modern
pharmacies are in most cases separate from physicians'
practices, that could be done also in the field of natural
medicine. I think that would be fine.
Of course, it is also true that a physician often
recommends procedures that he or she performs, so there is a
precedent in modern medicine for that also. But I don't
think that is the major issue, profit, and it could be dealt
with in that way.
MR. DUGGAN: I would simply add that I would favor
you taking policies favoring disclosure rather than setting
policies or regulation. Disclosure, disclosure, disclosure,
so it is out front, whatever. If you make a 15 percent
profit on your product, disclosure rather than regulation.
DR. GORDON: Thank you. Effie, Charlotte, and
then Joe.
DR. CHOW: I really appreciate the presentations,
and the wellness and the focus on the whole person with all
of you. I am familiar with some of your work, and I
appreciate it.
There is a big question that as CAM becomes more
accepted, and we strive to survive and go through research
and become validated, and that we like our practitioners to
survive, of course, in the same lifestyle manner that we
were used to, and that is wonderful, Bob, your students are
doing that.
Then there is a population we are talking about.
It sort of seems like only the middle class have access, and
even then it is tough. What are you folks doing in your own
institutions to help that, reaching out to the poor and the
ethnic groups, and as someone mentioned earlier, it was not
just the ethnic group. I have real concern because I have
been in this a long time, and it seems like it is the middle
class were sort of forced into it. But if you folks could
mention -- and what kind of recommendations do you have to
do that?
DR. HUDSON: I have done a lot of thinking about
that one. I think it is a responsible thing to do, to think
about one's privilege, and who is privileged to work with
you from an economic point of view. In my own personal
case, in our clinic, just from the physicians' standpoint,
we have three tiers of pricing, you might say, and it is
based on experience. We have a resident, and her fees are a
certain level, and then we have the people who are second
year or third year physicians, and then the third level. So
there are three different pricing categories that people
could have the option. There is quite a bit of difference
between those.
Secondly, for myself, I work one day a month at a
rural clinic where the prices are two-thirds less than my
normal urban prices. Then I also work at the naturopathic
college that has a sliding fee scale.
In our clinic, we have payment plans and outreach
in terms of some free clinic time in different communities
in the Portland area, whether that is by ethnic group or
economic group, or some combination of both.
MR. DUGGAN: We put about $200,000 a year, about 5
percent of our budget, into running an inner city clinic,
and we add to that specified time among all of our senior
clinical year students to work in those at about five or six
clinical programs in Baltimore. I am aware that at least
six or seven of our graduates have established similar
clinics, and that is why I mentioned the policy
recommendation of promoting the return to pro bono service.
I do every Friday morning in an inner city clinic, to be of
service, and a good number of our graduates do. So it is a
very specific policy of the school to promote, and our board
has been very deliberate, that whatever we are doing in
Columbia, Maryland to demonstrate this among the very
economically privileged, we must be doing at the corner of
Pennsylvania and North in inner city Baltimore, to show that
the same world applies and serves, and actually saves a fair
amount of money for the city of Baltimore health system.
DR. HUDSON: I want to add just one brief thing.
It is one thing that could go a long way for people
accessing naturopathic medicine, is that student loans -- we
cannot go, after we get our $100,000 student loan, we cannot
go work on a reservation or in the neighborhood in Baltimore
and get any part of our loan forgiven. That would be
something that I think you would see a lot of naturopathic
physicians wanting to go to those areas because of the
natural resonance and compatibility with ethnic medical
practices. In those communities we have had a lot of
naturopathic physicians wanting to go to rural areas. I
mean they want to be around all those trees and plants.
DR. SCHNEIDER: Our institution is part of a
federally funded CAM center which is a consortium that
includes two of the nation's four historically black medical
schools, and this CAM center specializes in research and
demonstration practices of CAM in high risk minority
populations. For the past 12 years, we have conducted a
series of randomized trials --
DR. GORDON: You said the magic word.
DR. SCHNEIDER: We have conducted a series of
randomized trials, the only trials to date of mind-body
approaches in high risk African-Americans for the treatment
and prevention of cardiovascular disease. Some of those
reprints are in your packets.
So we have been very involved with the nation's
historically black medical institutions in rolling out CAM
approaches in lower socioeconomic, ethnic communities,
particularly African-American communities.
Our next initiative is in Native American
communities and Hispanic communities and other ethnic
communities after that, as part of our federal CAM center.
DR. CHOW: We appreciate your volunteerism, but
perhaps if you have -- that is what a lot of CAM people are
doing now, you know, and if you have recommendations,
specific recommendations to see how that can be rectified.
I mean continue to volunteer, but how can we make it more
kind of viable? I would appreciate that.
DR. SCHNEIDER: I think it is reimbursement
policies. Many of our participants receive their care
through Medicare and Medicaid, and if those reimbursement
policies were in place for CAM, we and others have shown
high levels of patient satisfaction, compliance and
efficacy.
MR. DUGGAN: Actually, in inner city Baltimore, I
think in the project we run, if we were looking at outcomes,
cost outcomes and quality of life outcomes, rather than
mechanism, we would show that the cost of care for the
individuals coming through our clinic through the Medicaid
system is probably a great saving. But the design of a
study to show that is extremely complex and expensive. But
we are quite positive we save the city and Medicaid an
enormous amount of money each year through that, often by
simple education.
DR. HUDSON: I would echo that Medicare-Medicaid
reimbursement is nonexistent, basically, for naturopathic
medicine.
DR. GORDON: Thank you.
Charlotte.
SISTER KERR: Yesterday I said that I thought the
role of the prophet was one of imagination, and so I want to
ask you prophets, can you imagine any other ways to help to
help make CAM more easily accessible, other than by
insurance reimbursement or Medicare or Medicaid? And is
reimbursement really the solution? We think about
reimbursing acupuncture, naturopathic, but what is the basic
nutrient? What are we going to do about reimbursing people
who buy bottled water, or we may need oxygen masks soon to
go into certain sections of America? Maybe that will be
part of a reimbursement. Or should we subsidize the people
who are buying organic food for their medicine? So I want
to ask you, either now or in the future, to send
recommendations for other ways. Bob did cover that already,
I think.
MR. DUGGAN: We did a small study, Charlotte, as
you know, with the corporation where we put in one of our
graduates who happened to be a tai chi teacher, but also was
still making money as the key personnel benefits director of
a fairly significant corporation, put in minor CAM
interventions, and that corporation cut costs by 20 percent
over five years.
What we believe actually happens with the
educational component of CAM is that it becomes water cooler
medicine, and so people learn around the water cooler simple
ways of dropping out of the sick care reimbursement system.
The insurance reimbursement, the mechanism in that
is that it is the self-insured large corporations that
understand where the dollar saving is. It is not the
insurance companies. Almost all the insurance companies are
making a quarter point profit on a transfer between the
corporation and the beneficiary. The person paying the bill
is the large corporate employer, and the moment they realize
that they can 20 percent off by simple educational programs,
when you are looking at 100 percent increase over 10 years.
So it is the same thing that happened with Allied Signal in
'87, in the development of managed care and the explosion of
that. Some large corporation is going to take it and do
that. I don't think Medicare and Medicaid can do it. The
ideal thing would be for Medicaid to save a lot of funds by
doing that. I think it has to happen in the private sector
first. But that is why I urge a session on rethinking the
economics because all the economics now are designed to
disempower the patient, disempower the practitioner.
I asked a group of our graduates yesterday,
thinking of today, do they want me to speak for insurance
reimbursement? And to a person they said no, because it
perverts us and our patients. They don't want insurance
reimbursement, and the other side of the coin is the group
you are talking about, Effie, the poor, those who have no
access to this, we have to find a mechanism that provides
that access. But the driving force where the big money is,
is disincentives to wellness across the board.
So, yes, you need a very good economist to sit
down and rethink the policy or CAM is simply going to look
like the rest of the health care system.
DR. GORDON: I have a question just before we move
ahead.
Do you have a recommendation for someone whom we
could work with on that?
MR. DUGGAN: I know of two. I will check them and
get them for you. But I think it is a very important
conversation to have. There is somebody at Princeton, and I
don't want to mention names, but there are two or three
people who understand that issue.
DR. GORDON: And we very much welcome working with
you as well.
MR. DUGGAN: I will get that for you. Thank you.
DR. HUDSON: We probably need new Nintendo games,
would be my guess, on this topic. But more seriously, other
ideas that don't have to do with reimbursement might be
again coming back to this education in the schools. I think
that is really where it needs to start. I see that. It is
very sad for me in my practice to be talking for the first
time to a 50 year old woman about calcium in her diet, and
who already has osteoporosis, when it was a totally and
absolutely preventable disease, if we had been talking about
it much earlier.
Perhaps discounts on disability insurance for
people who have certain health practices. Perhaps some kind
of, I don't know if it is a tax benefit or some other
benefit, if you have a garden, a vegetable garden where you
are growing food. Perhaps a tax benefit to companies who
are involved in the natural products industry. And then I
think always leadership, you know, leadership in the form of
our president, our senators, our legislators, that somehow
if something could catch on and one of them really
popularizes it and becomes a leader in this area. That is
kind of what we need, is a leader.
DR. SCHNEIDER: Besides education and
reimbursement, perhaps the most important issue would be
access to CAM services for everybody, and that would be in
terms of practitioners. Now it is not legal for many or
most CAM practitioners to practice their art or science in
most states. Much is practiced, but not legally. If those
practice laws could be liberalized, like in Minnesota, so
CAM practitioners who are certified and gone through proper
training could practice, I think that would go a long way
outside of reimbursement and education.
After all, most of the $60 billion a year spent in
this country already on CAM is not reimbursed by third-party
payers, and is out of pocket, and almost half of Americans
use those services now if they are accessible.
DR. GORDON: Joe.
DR. FINS:
MR. Duggan's testimony talked about
sort of understanding fundamentally what this movement is
all about, and that prompted me to look at
DR. Hudson
technically a little differently, and I was wondering if you
have had the opportunity to think about the relationship
between the CAM movement, because I think demand really
drives access of delivery, and the development of the CAM
movement and the women's movement in self care and natural
childbirth. There is sort of an implicit message and I was
wondering if you could say more about that and help us make
sense of this phenomenon a little better.
DR. HUDSON: Well, you can help steer me if I get
off track here, but I can, I think, best try to answer that
by my own experience. People often ask, you know, how did I
become a naturopathic physician, and my answer is that
really it is I am 48 years old, and my life experiences
include graduating from high school in 1970 with the first
Earth Day movement. It was also in the early '70s you had
the feminist movement, the self help movement, the back-to-
the-land movement, and all those have converged, I think, in
my life at this age to evolve this interest and passion and
drive about alternative medicine. I think those are
probably common forces on many people, both practitioner and
consumer. The feminist movements, women's movements, is
certainly about empowering one's self and taking
responsibility for one's life, and being more self directed,
and calling upon inner forces to fully evolve. And I think
all that language is applicable.
DR. FINS: And I would just add one other point,
is that the feminist movement has been very good at getting
us to ask questions about hierarchies and power
relationships.
DR. HUDSON: Yes.
DR. FINS: So I think it would help for us to sort
of put this new movement into the context of movements with
which we are more familiar, and we might have had 20 or 30
or 40 years of experience with because there is a lineage,
and I think your testimony sort of raises that. So thank
you.
DR. HUDSON: Thank you for asking that.
DR. GORDON: Wayne and Tom. We need to end by
12:30, so we can have an hour for lunch, and if we have
time, but I really want to end promptly so we don't hurry
through our lunch.
DR. HUDSON: A good health practice.
DR. JONAS: Well, as usual, the profound questions
have already been asked, so I will go back to the mundane.
[Laughter.]
DR. JONAS: I had a question for
DR. Schneider.
It seems to me like you have pretty significant data, at
least as good as the orange data, in terms of significant
improvements in health and cost benefit, and this type of
stuff, and I am just wondering, have there been any
insurance companies that have picked up and said we are
going to do a demonstration project, or we are going to
incorporate this like has occurred in that program that we
just heard about?
DR. SCHNEIDER: Yes, there are several large
corporations, several Fortune 500 companies, which now
reimburse their employees for learning the TM program, the
major mind-body approach of Vedic medicine, and they do that
because of noted reductions in health care costs and
improved productivity.
There are indemnity insurance companies and HMOs
are considering Vedic medicine, but right now it has been
largely in the corporate sector and self-insured sector.
DR. GORDON: It would be useful for us to have
that data as well, in terms of making recommendations.
DR. JONAS: May I just extend that to the other
panelists, to see are there others that have had that picked
up by insurance companies or corporate companies, their
entire practice? I am not talking about elements of it, but
the practice itself? I think we have heard a fair amount,
actually, about some of the naturopathic stuff that is going
on in the Northwest, but has that happened, Bob, in D.C.?
MR. DUGGAN: It is getting a major commitment with
the large corporations. We have two relationships with
getting the research component in them, working with making
the distinction for corporations between -- what we have
worked on is making distinctions between acupuncturists who
are educationally-oriented and acupuncturists who are
technique-oriented, and what we know in that study, we did
the same study at six clinics. In all six clinics, the
symptomatic outcomes were the same, but the two clinics
where there was a lot of education, the patients had a
different level of satisfaction. It was a very different
statistical outcome, and we have two corporations now, in
fact, one very large corporation shifted their whole
insurance program recently, and we had designed a very
specific program which led, if the practitioner didn't
educate people in self care, they wound up having to deliver
free care. And when the corporation tried to end that
program, although as far as we know, no one is delivering
free care, it has been very successful, the corporation
couldn't end that. They couldn't fold it into the brand new
national program, and they had to put that as a special set-
aside program for them. A company with about 4000
employees. And we were surprised that the benefits manager
found that she could not shift that design that was in
there.
DR. JONAS: Why?
MR. DUGGAN: Why?
DR. JONAS: Was it because of the --
MR. DUGGAN: Educational component.
DR. JONAS: Yes.
DR. GORDON: Tom.
MR. DUGGAN: The employees protested when it was
about to disappear.
MR. CHAPPELL: If you could just respond or
brainstorm with me for the couple of minutes that I have got
left on the question of how do we provide the supply of
funds for the freedom of choice of services? If it is not
the reimbursement model, and we certainly struggle with
that, then the only other things that I know of that are
going on in our society are Social Security, which is a
deduction we could have for wellness promotion, as well as
Social Security. We could have a payroll deduction at
corporations that are income tax deductible to those
corporations that are providing some contribution to that
individual's wellness program. I mean, for me, this has
been a self-help, self-care initiative for the 20 years, 30
years that we have been around, and it still is, in my
opinion, no matter how much we work with the professional
context of this, it is still being driven by consumers,
increasingly self-educated, self-regulated consumers.
So I am struggling with how can we put money in
their hands, rather than that in private managed care hands,
who will tell you how much you are going to get for your
procedures and so on. So I am thinking of how do we get the
supply of money into the hands of the consumers first.
MR. DUGGAN: I believe, I don't know the exact
statistic, but the amount of money spent in the six months
before death is probably 25 percent of the national health
care budget. Deeling Evangeles' [ph] book in 1974, "Limits
to Medicine," points out that a culture that attempts to
prevent death will spend itself out of existence in that
attempt. The cultures that have a different attitude
towards death spend about 8 to 9 percent of GNP. We are
close to 16. So I say to consumers, if you work to reorient
the concept with the aging population, we have to deal with
this.
I was at a meeting the other night of the leading
corporate executives in Howard County, Maryland, and we had
the head of a hospital system and the head of an insurance
system. The head of the hospital system was talking about
the new high tech care coming on line. The head of the
insurance system said, well, we can't afford to pay for all
of that. We don't know what we are going to do, and I
thought I was going to have to get up and say something, but
thank God, one of the physicians who is head of the hospital
physicians' practice got up and said, well, everybody in the
room has a lot of suffering, and we are all going to die,
and we have to rethink our relationship to suffering and
death. I think the economics would show if you reorient the
way we deal with dying, and if you reorient the way we deal
with functional, nonpathologic visits to any health
professional, you then move a significant economy into that
free base to support wellness. That is why I am talking
about the economic design has to be shifted.
My mother -- and I went it through this year with
my stepmother -- she was ready to die, and I wasn't there,
but the automaticness was for her to spend three weeks in a
hospital where we had to get her back off the tubes, rather
than have said, mom, it is time for a good bottle of Irish
whiskey. Let's all sit down together, we are going to let
you die at home, without all the tubes. She was 91.
Now I have been through that three times with
family in the past year. The enormous expense in those last
six months of life, well documented, is where the pot of
money is. And the other pot of money is in whatever
percentage it is that corporations spend on MRIs, when it is
pretty clear that the person is not eating breakfast, lunch
and supper, and they have a headache.
Now that is the educational component. The money
is there, it is not adding a new tax base to finance this.
The corporations aren't going to do that, the government
isn't going to do it. We have to understand where the pot
of money is that has to be shifted. That is why I put in as
one of my recommendations a strong sense of the relationship
of CAM, hospice, and palliative care, so that we reshift --
and if we don't do that pretty quickly for the elderly
population, we are not going to afford the care that is
demanded for the aging population. So there is a pretty
sophisticated economic analysis that goes on here. But the
money is there. It is just now being used in the wrong
ways.
DR. GORDON: Effie?
DR. CHOW: I am very excited about the gist of
this conversation because we have been primarily talking
about how can we research CAM, and talking about techniques
and methodologies, and I would love to -- no time for
discussion now
-- but I would love for you people to send more input on
this avenue.
For example, Tori, you talked about, let's teach
people to go back to the garden, like have your own
vegetable garden, because organic food stores are very
expensive.
DR. GORDON: Thank you. Thank you all. Thank you
for opening the discussion and deepening it for us as well.
We will adjourn now for lunch until 1:30. We will
start promptly at 1:30.
[Lunch recess taken at 12:30 p.m.]
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