Stephen Bolles, DC

Shortly after publishing the

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Questions that the NCCAM Data Raise:
Is the CAM Industry Mature, Immature or Simply Misunderstood?

Stephen Bolles, DC

The thing that stood out to me initially, as to everyone, were the bold numbers (in NCCAM's findings). Hard on the heels of that came the head-scratcher of the familiar issue: How many people in how many ways have tried to capitalize on these numbers in various types of service businesses?

	I'm beginning to wonder if some new model of looking at the CAM/integrative health care markets may be required.

The products businesses do well with good products and good business planning, but the service side of things seems off somehow. I've wondered if the CAM service segment of health care is either a) mature, and this is (or was) as good as it's going to get; b) mature, fragmented but possessed of a reservoir or latent energy that hasn't been effectively tapped or focused; c) immature, missing some type of focusing or developmental dynamic required to guide or direct it; or d) simply misunderstood in the terms we are using.

Much as there's talk about new paradigms in viewing health and disease, I'm beginning to wonder if some new model of looking at the CAM/integrative health care markets may be required. I am wondering if it ends up being helpful to develop a model that layers types of markets on each other--separated by some distinction in the consumption dynamics.

You know how many people have been seduced by the dollar numbers that have been available, in one form or another, since Eisenberg's initial study.

I am not sure yet what the categories might be based on, but one initial thought might be to base them on identifying the beneficiary of the transaction. Or whether the consumption was based on controlling disease/fixing problems vs. promoting/assuring wellness or avoiding malaise. Or whether consumption decisions are based on a relationship with someone or not.

I am not sure, but it seems to me that without some new model the NCCAM data as interpreted really don't tell us much that's useful. To me it's kind of like an eloquent and detailed answer to a problem that hasn't been defined. The market segments are clearly related and interconnected, but I am wondering if the NCCAM results are confusing in part because of the lack of this distinction.

I share, I think, your suspicion of the numbers, and not just because CAM use appears flat or contracting. You know better than most how many people have been seduced by the dollar numbers that have been available, in one form or another, since Eisenberg's initial study. I wouldn't even venture to guess how many business plans have been written where those numbers stand as testament to the richness of the opportunity; just reviewed another one this week that could have been written twenty years ago--and probably was. But as we observers and pained members of the Fraternity of The Failed can attest, actually getting at that revenue flow is harder than it looks. It has challenged me to think of how one might be able to predictably, effectively and reproducibly carve off a chunk of those dollars. They're clearly flowing out there, somewhere. But I don't know if anyone's found the secret sauce yet.

	As we observers and pained members of the Fraternity of The Failed can attest, actually getting at that revenue flow is harder than it looks.

Perhaps that is because we've failed to appreciate the right marketplace segmentation model. From where I sit, I think there is a persistent misunderstanding of what may be the basis for a consumption decision--the calculus of value that goes into someone buying something from someone (more than once, which I think you astutely identify as an important metric in returning or sustained CAM treatment). I think that without that understanding, its easy to come up with research answers that don't explain anything.

To me this misunderstanding is evident in mainstream CAM provider business practices. It looks to me like they seem to be on a collision course with a dire and painful marketplace shakeout and financial reckoning. One of my soapbox statements is that chiropractic, after 114 years of existence, has been at a flat market penetration rate of 7-10% for decades--but churning out graduates at a rate higher than population growth can absorb and keep practices flat or growing. That's not a recipe for success.

As hard as CAM professions are working to become embedded in the delivery system, the healthcare transaction system has been moving to put consumers in a position where the delivery system matters less and less.

I don't think people don't use CAM carelessly. They may use it without guidance; they may use it experimentally, but because it costs real money for just about everyone, it's not possible for many people to use it without concern. As I look around the professions I know, it strikes me that most of what I see are strategies of systemic engagement. As important as those are, I worry that as hard as we continue to work to become embedded in the delivery system, the health care transaction system has been moving to put consumers in a position where the delivery system matters less and less. If health care consumption decisions are coming to be based more and more on retail decision dynamics, I fear for our future, because I don't see many visible conversations about how to focus on the issue of value as a way of promoting consumer adoption. We providers tend to see our services in terms of solutions to problems people come in the door with, but many consumers, I believe, are coming to think in very different terms--because they employ a calculus of (often very personal) components of value. Clinical and functional outcomes certainly matter. But price, access, amenities, bundled providers, peer network support, are also factors I don't hear us talking about very much. They are marketing adjuncts to some, but not adoption strategies for many.

	I fear for our future because I don't see many visible conversations about how to focus on the issue of value as a way of promoting consumer adoption.

I think this matters at all because of how we CAM providers have most frequently tried to position ourselves in our own marketplace. The terms I hear and have tracked over time now, I fear, have become not irrelevant but incomplete. I fear that our strategic position has kind of ossified, and I'm not sure we understand what's going to be required of us in the coming iterations of health care delivery and transaction financing (regardless of health care reform). I badly want to be proven wrong on this.

For instance, it seems that CAM providers should be loved by insurance plans, but insurers don't care if we save them money. Chiropractic has unsuccessfully argued this for years, with very few takers. Insurers only ended up caring whether they could successfully control our costs. Short of sheer lobbying force, coverage for other providers' services has only come (I would submit) from insurers' ability to sell coverage products to someone. That's why, in my view, we've ended up with discount affinity products dominating the marketplace. We have not succeeded in describing our value in terms that matter to the industry, and the terms of value that insurers' customers can articulate have found the appropriate match: discount affinity products.

If we're asking the same questions we were 30 years ago, we are probably not asking the right questions now.

So back to NCCAM. Outside of the important statistical characteristics you identify, I think that one of the problems in understanding the data in comparison to prior studies goes to the difference in markets. The health care marketplace in the early 1980s [when the CAM movement began gaining momentum] is quite different than today. The expansion and contraction of insurance coverage for CAM notwithstanding, the generational shifts, profound changes in transaction tools and dynamics, the worsening of the national chronic disease emergency that have taken place in the last 30 years all say to me that if we're asking the same questions we were back then, we are probably not asking the right questions now.

But at least we're asking them, and challenging what we think we know can only improve our understanding.

Peace and health,

Stephen Bolles, DC

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