| | Integrative Medicine and Integrated Health Care Round-up: April 2010 | |
Summary: What integrative practice associations are saying about healthcare overhaul ... CMS/Medicare nominee Berwick and his principles for integrative medicine ... Patient outcomes from Penny George Institute inpatient integrative care ... Ground-breaking Healthpoint expands integrative model in community health; Breed comments ... NCH's Gahles reports on meeting of top homeopathic researchers with NCCAM team ... Anti-NCCAM bloggers take invite from NCCAM's Briggs ... Outcomes of Medicare chiropractic demonstration project confusing, under examination by ACA ... Ford pilot shows lowered use of drugs by acupuncture and mind-body group ... Merrell and integrative medicine featured as cost-saving in NYT ... Update on action at Wake Forest integrative medicine ... First inpatient acupuncture fellowship at New York's Beth Israel ... Maizes clip highlights decade plus of changes at Arizona Center for Integrative Medicine ... Western States Chiropractic College becomes University of Western States ... Tri-State Acupuncture College publishes white paper on inter-professional education ... Ornish challenges thinking in New York Times piece ... Bravewell leaders in Vanity Fair ... Acupuncture positively portrayed in Wall Street Journal ... Robust SPARC/OCIM gatherings in Portland, Oregon ... Massage Therapy Foundation receives $30,000 NCCAM conference grant ... Educators Schwartz and Lowe team for online education business ... Caldwell heads AHMA ... O'Connell to exec post with ACA ... Naturopathic doctor Cronin in the cover of Phoenix Magazine "Best Doctors" issue ... Marchiori selected as new Palmer chancellor ... Huggins elected to AHPA presidency, plus more ...
Policy
 Health reform impacts on integrative practice fields
Later this month, the Integrator will publish a Special Report
on the Obama-backed and Pelosi-driven healthcare overhaul legislation and its
impacts on integrative practices. Meantime, here are some links to what
integrative practice stakeholders are saying:
Comment:
Whatever one thinks about the
legislation that passed, there is no question that all of the licensed
integrative practice disciplines
are more specifically in the game than they have ever been in the past.
If
these professions connect the dots between the various levels of
inclusion in workforce
planning, comparative effectiveness research, wellness and health
promotion,
medical homes, community health teams and the critical
non-discrimination clause,
a constellation clearly emerges of a new presence for integrative
practice in federal
US healthcare policy. More soon.
 Berwick: Up for CMS post
A March
27,
2010 article in the New York Times indicates that Barack Obama
plans to appoint Donald Berwick, MD, MPP, FRCP, as director of the
Centers for Medicare and Medicaid Services. Berwick is the founder and
director of the influential Harvard-based Institute
for
Health Improvement, through which he led the 100,000
Lives
Campaign to clean up medical errors in US hospitals. Berwick
considers himself an
"extremist"
advocate for patient-centered care, partly based on his
own troubling experience with the system as a patient. Some have
challenged Berwick for the CMS position based on his lack of experience
in running a large agency. Others highly
laud Obama for his choice.
Berwick was among the presenters at the February 25-27, 2009 Institute
of
Medicine (IOM) National
Summit
on Integrative Medicine and the Health of the Public.
Comment: This potential appointment is extraordinarily on target. Anyone who supports patient-centered care and
integrative practices would be smart to do all they can to make sure the appointment
is not held up. Consider, merely from the integrative practice
community, that he not only showed up for the IOM Summit, he also made a
significant, thoughtful contribution. Here are the "Principles for
Integrative Medicine" Berwick offered attendees.
Berwick's Principles for
Integrative Medicine
- Place the patient at the center.
- Individualize care.
- Welcome family and loved ones.
- Maximize healing influences within
care.
- Maximize healing
influences outside
of care.
- Rely on
sophisticated, disciplined
evidence.
- Use all relevant
capacities - waste
nothing.
- Connect helping
influences with
each other.
Berwick is quoted in the
report on the IOM meeting as concluding this way:
"The sources of suffering are in separateness and the remedy is in
remembering that we are all in this together. Integration, if it is to
thrive, is the name of a duty to contribute what we can to a troubled
and suffering planet." This is wisdom, a rare treat in a leader of a huge bureaucracy. The United States will be lucky to have him in
this critical
moment.
Integrative Services
 Integrative care inpatient programs produce positive outcomes
A study conducted by Jeffrey Dusek, PhD,
and including a top-notch team of Michael Finch, PhD, Gregory Plotnikoff,
MD and Lori Knutson, RN, BS-HN examined the results of integrative inpatient care on 1837 patients. Of these, 66% had never before used integrative services they received. The researchers are all part of the inpatient care team of the Penny George Institute for Health and Healing that is part of Allina Hospitals and Clinics. Results were published in the Journal of Patient Safety as "The Impact of Integrative Medicine on Pain Management in a Tertiary Care Hospital." Here is the conclusion:
"The formal provision of inpatient
integrative medicine had a significant impact on pain scores for
hospitalized patients, reducing self-reported pain by more than 50%,
without placing patients at increased risk of adverse effects. This was
true in all 6 settings. Age, previous use of complementary therapies,
and sex did not affect results. Future research must define the
appropriate dose of the intervention, the duration of the relief, and
the identification of patients most likely to respond to these
nonpharmacological treatments. Additionally, future research using the
electronic health record will allow quantification of any reduction in
total costs, pain medication usage, and adverse events."
Following a query from the Integrator, Knutson confirmed that this is the patient population on which the team has estimated there was a $2000 average savings per patient which Knutson had previously reported. The savings were linked to decreased length of stay.
Comment: The robust George Institute inpatient initiative, which has delivered over 60,000 inpatient integrative visits, would optimally have a full-time staff of a half-dozen researchers and support staff continuously slicing and dicing that experience. It is clearly the most significant demonstration opportunity in the country, if yet limited in its service offerings. This is one of the best settings to help answer the question US Senator Tom Harkin posed to NCCAM when he charged NIH NCCAM in 1998, in Section C of the NCCAM mandate, to "study the integration
of alternative treatment, diagnostic and prevention systems,
modalities, and disciplines with the practice of conventional medicine
as a complement to such medicine and into health care delivery systems
in the United States." To this point, this focal interest of the Senator and his colleagues has been poorly engaged at NCCAM. Here's hoping that the NCCAM advisory council and staff will place fulfilling on this charge near the center of NCCAM's investment in the 2011-2015 strategic plan in development.
 Integrated community health model expands
In 1996, Community Health Centers of
King County, now Healthpoint, began the
first government-funded integrative services program in the United
States. The widely reported initiative, under the direction of CEO Tom
Trompeter, MHA, chose to continue offering the services after the
subsidy expired. The homepage begins with this unusual descriptor: "Welcome to HealthPoint. We provide medical and dental
care, as well as
complementary and alternative services, at 12 King County locations."
Healthpoint stayed this course when it recently
moved its Kenmore clinic into a new facility in Bothell, Washington.
There, employee Christopher
Crumm, ND, LAc offers both naturopathic medical and acupuncture
services each Wednesday. (He also works 3 days a week at
Healthpoint's Eastside Redmond facility.) Cindy Breed, ND, Healthpoint's "lead
provider for Natural Medicine program" is the subject of
the
audio interview in the March 2010 issue of Natural Medicine Journal.
Breed is affiliate clinical faculty and
residency director for the
Bastyr University Residency Program which HealthPoint also supports.
Employed natural health practitioners are on staff in all 8 clinical
facilities.
Comment: Credit Trompeter for holding
the vision and maintaining the model through a tremendous roller-coaster
of budget cycles and funding challenges for all community clinics.
Breed, interestingly, has also been there since the beginning. Let's hope the services are still there after the current, crushing cycle of funding retraction.
Research
 Gahles: NCH president set up the NCCAM meeting
Top homeopathy researchers
recently met with NIH NCCAM leadership to explore NCCAM's relationship with the
field. The meeting was organized by Nancy Gahles, DC, CCH, RS Hom(NA),
president of the National Center for Homeopathy. The topic: "Homeopathy Research - State of the Science
& Future Recommendations." Gahles'
top-flight international team included Iris Bell, MD, and Molly Punzo, MD, who were
with her at the NIH and, via teleconference, Martin Chaplin, Rustum Roy, Stephen
Baumgartner, Harald Wallach, Klaus von Ammon, Peter Fisher and Claudia
Witt
(via slides). NCCAM's director Josephine Briggs, MD, deputy director
Jack Killen, MD, Richard Nahin, PhD, MPH and 3 others filled out the
NCCAM team. Gahles team began by presenting NCCAM with a "6-inch binder
of research."
 Bell: Top researcher onsite as part of NCH team
Comment: One of the perverse pleasures
that comes from the disposition of the NIH to hire NCCAM leaders who
have no prior experience in alternative or integrative medicine is to consider the resulting challenges to move from the comfort zone of drug research on
botanical medicines into the far reaches of of "alternative medicine" such as homeopathic theory and
practice represent. In fact, forms of energetic thinking are infused throughout
the "CAM" universe. It is probably good that Briggs' extensive and
admirable self-education process of the last 2 years preceded this
meeting. The culture shock may have been too much had it been in her
first months. Credit Gahles for her gumption in pulling her field into
this meeting and the NCCAM team for taking it.
 Novella: In the office he'd like to shut down
A trio of anti-CAM bloggers who have called for de-funding and shutting
down NCCAM recently held a meeting with an NCCAM team that included
director Josephine Briggs, MD and deputy director Jack Killeen, MD. In a
blog posting entitled "Our Visit with
NCCAM,"the meeting is reported by one of the attendees,
Steven Novella, MD, a member of the faculty at the Yale School of
Medicine. Briggs reportedly requested the meeting, which included Novella
and his colleagues David Gorski, MD, PhD and Kimball Atwood, MD. One
area of concern for the bloggers is NCCAM "putting the cart before the horse" by doing
pragmatic trials prior to mechanism and efficacy research. They report
that Briggs "defended the utility of
pragmatic studies but also acknowledged our
concerns." The bloggers then pressed a favorite issue, urging that NCCAM not
even consider funding of homeopathy research. The reported answer: "Dr. Briggs response was that in the last two years (under her
directorship) the NCCAM has not funded any studies of homeopathy, which
is true. However, they still accept applications for homeopathic
research, but none have made it through the review process and been
awarded funding." Novella then pressed NCCAM on his view that
NCCAM's website effectively validates therapies and approaches. He notes that "the
one concrete result of the meeting was an offer to have experts from
SBM review NCCAM material before it is published. We, of course, agreed
to offer our services."
Comment: Josephine Briggs,
MD, deserves
the Obama Big Tent award for her proven interest in sitting down with
everyone,
no matter which party affiliation or belief. (Some have said this was
proven in early 2008 when Briggs met
with me.) Arguably, Briggs takes her
openness to dialogue further than the President. While Obama keeps arms length from those calling for the demise of the USA, Briggs
invited a meeting with those who have been lobbing bombs at her professional
home for years, calling steadily for its destruction. Briggs'
offer of review of content is disconcerting. For instance, has the director of NIH's National
Heart Lung and Blood Institute asked Julian Whitaker, MD or
the chelation doctors with American
College for the Advancement of Medicine to review their content on their
site?
I am intrigued by Briggs actions, as I am with Obama's strategy. At the same time, just as I often want Obama to play to the progressives that got him elected, I want Briggs to respond above all to the wishes of the practitioners, patients and other stakeholders who actually offer, cover, include or receive integrative services. That said, what would have been especially interesting is if Briggs' scheduler crossed wires and the bloggers and homeopaths had showing up for the same meeting time.
Costs
 Chiropractic demonstration findings raise questions
In 2003, the American
Chiropractic Association (ACA) took a
bet with Medicare that expanded coverage of chiropractic services would
be at least cost neutral for the agency. In January 2010, HHS Secretary Kathleen Sibelius
submitted her final report to
Congress on the 2005-2007 demonstration project that Medicare began
following the Congressional mandate. Patients rated the
pilot highly across the board. Yet cost results were radically
different, based on location. In the demonstration's New Mexico, Maine
and Virginia sites, the expanded coverage was cost-neutral or better for the
global neuromuscoluskeletal (NMS) costs that were measured. But in the 4th site of
Northern Illinois, where 2/3 of the dollars were spent, Medicare showed
losses of $50-million. Now Medicare is
looking to recoup $50-million through a lowering of reimbursement rates
for chiropractors. ACA formed a team including
health services expert
Christine
Goertz, DC, PhD and the ACA's Medicare coverage expert Susan McClelland to
explore the huge variances between sites. The biggest question: Why is
the
Chicago
area such a costly outlier? There is no indication now when the ACA
examination will be complete. Meantime, ACA is opposing the
reimbursement decrease. An Integrator article including interviews with
Goertz, McClelland and others is published
here. The ACA maintains a resource page on the project here.
 Goertz: Part of ACA team
 Talamonti: Ford leader backed pilot
A pilot study conducted with assembly workers
at the Ford Motor Company in Louisville, Kentucky utilizing acupuncture and
mind/body therapies in conjunction with conventional medicine provided the same outcomes as conventional back pain
therapies,
but reduced the use of pain medications among participants by 58%. The findings were published in a letter to the Journal of Occupational and
Environmental Medicine as An
Integrative Medicine Intervention in a Ford Motor Company Assembly Plant. In the study, one group received conventional pain management
therapies, including pain medications. The second group utilized
integrative
therapies, including acupuncture and relaxation/meditation CDs. Both of the groups received treatments over a six-week
period, with a 12-week follow-up. Kenneth
R.
Pelletier, PhD, MD(hc), a co-principal investigator on the study commented, in a release from HealthyRoads the provider of the CDs, as follows: "While the
sample size was insufficient to adequately estimate the effect of the integrative medicine
intervention on disability or absenteeism, the results have very
positive implications for employers looking to
manage their pharmacy costs associated with low back pain." Back pain is estimated to cost employers as much as $100 billion a year in direct medical expenses,
lost
workdays, reduced productivity, compensation payments and legal charges.
A release on the project is published here.
Comment: The leader at Ford, Walter Talamonti, MD, offers an insightful look at the challenges one can face in doing research in the onsite, employee-employer environment in this Integrator story.
 Merrell: Promotes integrative medicine as cost saving
The headline across the page of the New
York Times on
March 27, 2010 ran “Doctors
Offer Thoughts on Cutting Healthcare Costs.” There
followed 9 short statements of 100-200 words each from a diverse set of
medical
doctors. Examples: “Change Malpractice Law,” "Insure Catastrophes Only,”
and “Rely
on Evidence.” Then, prior to “Stop Overtreating” and “Restore the
Humanity” was
this: “Use ‘Integrative Medicine.’” The author, Woodson Merrell, MD, is
the
chair of the department
of integrative medicine at New York’s Beth Israel
Hospital (NYBI). Merrell referenced a Beth Israel study that found that
breast cancer patients
using hypnosis cost the hospital $772 less overall compared to those
who didn't. Said Merrell:“That’s an example of how a
simple technique can help patients and reduce costs.”
Comment: These outcomes, from hypnosis, appear to be huge. Of course, the question begged
here is whether any hospital sees this "savings" as a benefit or as a loss of
income. Somebody got paid less. As Duke's dean emeritus Ralph Snyderman, MD stated in a
recent JAMA editorial in which he referenced his experience with an integrative strategy, incentive structures can hamper adoptions
of cost-saving approaches. (Snyderman's statement was covered here
in the Integrator.) Regardless, it was nice to see Merrell and
integrative medicine elevated to meaningful here.
Employers
 Pelletier: CHIP hits 25th anniversary
The Corporate
Health Improvement Program (CHIP), the longest-standing research program
between major medical schools and Fortune 500 corporations, this year
celebrates its 25th anniversary. CHIP was founded by Kenneth R. Pelletier, PhD, MD(hc). According to a release from the Arizona Center for Integrative Medicine where it is housed, CHIP's mission is to "respond to
the need for creative solutions to an unchecked rise in medical-benefits costs
incurred by businesses nationwide." The release notes that the organization's research
and publications "have been a major driving force in demonstrating the clinical
- and more recently, integrative medicine - cost value of prevention." The program is a collaboration between the academic health center and 15 major corporations, including Canyon Ranch
Resorts, American Specialty Health, Ford Motor Company, Dow,
Thomson/Reuters, Corning, Prudential, IBM, Mercer, Pepsi, NASA, Pfizer,
and
Walgreens. One outcome of CHIP's work is the integrative medicine for back pain pilot at the Ford Motor Company noted in this issue of the Round-up. Other CHIP projects include: work with NASA to develop an objective
assessment tool of worksite stress; and a research project with Prudential that is
designed to prevent the conversion from short-term disability to
long-term disability.
Comment: Pelletier, an Integrator adviser, was and remains one of the few voices to trumpet the potential value of bringing health promoting integrative practices with the health-creating and productivity interests of the employer community. As a sometimes organizer, I particularly appreciate Pelletier's success with the challenge of holding together a shifting but always significant set of dues-paying members for this period of time.
Academics
 Kemper: Wake Forest IM leader
Since 2006, the Integrator has tracked various developments at
the Center for Integrative Medicine (CIM)
at Wake Forest University Baptist Medical Center (WFUBMC). CIM's
co-sponsorship of the Society for Acupuncture
Research 2010 International
Conference in March 2010 prompted this update. CIM is partnering with
the Maya Angelou Center for Health
Equity (MACHE) also at Wake Forest and the Claude Pepper Older
Americans Independence Center on pilot research projects. According to
Lauren Azevedo, the program manager with CIM, the pilots focus on "cancer disparities, cancer
and aging, and integrative medicine with cancer patients or assistance
with
their caregivers." In addition, the
WFUBMC
Department of Nursing and Caregiver Stress Task Force developed a
program entitled
"Healing Touch Therapy: Caregiver to Patient/Family." The program
includes policies and
procedures "to reduce stress and promote healing in caregivers,
patients and
families, and to ensure consistency in Healing Touch practice." Azevedo adds that the Wake Forest School of Medicine began offering
Integrative Awareness Training (IAT) to medical students in 2009. The
program, says Azevedo, "focuses on learning mind-body skills that
promote self-awareness,
self-reflection and self-care." In
addition, Mental
Health, Naturally authored by center director Kathi
J. Kemper, MD,
MPH, FAAP was published in March by the American Academy of
Pediatrics. A prior Integrator
look at massage
services is here. The center's
newsletter is available to those who wish by contact Azevedo at
[email protected].
 Nielsen: Directs inpatient acupuncture fellowship
Nearly 20 licensed acupuncturists have taken advantage of the nation's
first inpatient fellowship for licensed acupuncturists which began in
September 2008. The program is based out of the department
of integrative medicine at NYBI (see
above) that is associated with the Continuum
Center for Health and Healing, one of the nation's largest
integrative clinics. The yearlong fellowships are led by Arya Nielsen, PhD, LAc and Ben Kligler, MD, MPH. They benefit from a close relationship with an integrative medicine program
for medical doctors which Kligler runs. Participants have at least 2
4-hour shifts each week, and have an additional 3 hours per week of
typically interactive, didactic training. A research component is also
included. The cost: $3500. For details, see this
longer article.
Comment: As
becomes clear, this exceptional opportunity, thanks to the work of
Nielsen, Kligler and Merrell (noted in the costs article this issue of the Round-up), is
still largely possible only as a labor of love. Nielsen notes that some
fellows think they should be getting paid, and Nielsen agrees. Yet the
business model of the hospital has the acupuncture services provided for
free. Thus, there is no income to justify the expense. My estimate is that the fellows
are generating between $100,000 and $200,000 of value to the
hospital's patients, depending on whether the inpatient services are
valued at $20 or $40 each treatment. At $60, we're talking $300,000. It would be nice to see this work
made sustainable on something more than heart.
 Maizes: Video of IM leader provides short history of influential Arizona program
Anyone curious about the evolution of the program in integrative
medicine, founded by Andrew Weil, MD in 1998 at the
University of Arizona, into the Center for
Integrative Medicine that it is today, will find this
5 minute video illuminating. The video features the Center's
executive director, Victoria
Maizes, MD, MPH. Maizes succinctly summarizes
twelve years of work on the Center's fellowship and integrative
medicine in residency
programs.
Comment: Sometimes people find the
perfect work. I am thinking Maizes must feel that way about landing her
job at what is now the Center for Integrative Medicine, after being one
of the former Program in Integrative Medicine's first residential
fellows. Credit Weil for the vision, his ongoing financial backing,
and his wisdom in hiring the likes of Maizes. While other academic centers have made significant
contributions, imagining the development of academic integrative
medicine without the influence of the Arizona Center for Integrative Medicine is to view a very
different, less mature, less holistic and less ambitious entity. Take a listen. The
contributions are remarkable.
 Brimhall: Leads college to university status
The only college of chiropractic medicine in
the Northwest
of the United States quietly shifted its profile to reflect its
actually status
early this year. Western States Chiropractic College became the
University of
Western States (UWS). Joe Brimhall, DC, the university's president, shares that “the board
decided about three years
ago to pursue University status and we’ve been working on it since
then.”
Besides chiropractic, the university offers a massage therapy program
and is now rolling out a masters degree in
sports and rehabilitation. Brimhall, who led the transition, is an
accreditation
expert. He is past president of the Council on Chiropractic Education, a
commissioner of the Northwest Commission on Colleges and Universities and chair of the Accrediting
Agency
Special Interest Group of the Academic Consortium for Complementary and
Alternative Health Care. UWS is already regionally accredited.
Tri-State College of Acupuncture publishes report on
interdisciplinary professional education
The newborn Center for Acupuncture Educational Research and the Tri-State
College of Acupuncture have jointly published a 20-page report
entitled "Integrative Medicine and Interdisciplinary Professional
Education (IPE): A Report on Theories, Practices, Trends and Funding
Opportunities." The document may be the first significant focus on IPE to come directly the acupuncture and Oriental medicine community. Anya Kaplan-Seem, a
research assistant at Tri-State, wrote the report.
Kaplan-Seem provides an exceptional introductory review of key reports
relative to AOM and other integrative practice educators, including the
seminal 1994Pcew-Fetzer document on relationship-centered care, the National Education
Dialogue to Advance Integrated Health Care (published by the Integrated
Healthcare Policy Consortium), the competencies for integrative
medicine endorsed by the Consortium of Academic Health
Centers for Integrative Medicine and recent IPE research.
Comment: I take it as a sign of
maturity that a component of the AOM community, which has an advanced
tendency to stick inside its own silo, is focusing on IPE. Under my
hat
as director of the Academic Consortium for Complementary and
Alternative Health Care, where bettering care through IPE is core
mission, I particularly salute Tri-State for this useful publication. Here's hoping they can find what they need to take
the Center from idea to established force in the AOM community. The document is not presently internet available. Email me if you have an interest in seeing it.
Media
 Ornish: Challenging the therapeutic approach
The April 3, 2010 New York Times letters-to-the-editor included a
submission from Dean Ornish, MD which frames the journalist and policy
task in
a health promoting light. Referencing a March 31, 2010 front page story
“Plan
to Widen Use of Statins Has Skeptics,” Ornish writes: “The wrong
question is
being asked. It’s not 'Should Crestor be given to reduce inflammation?’
It
should be: ‘What is the cause of chronic inflammation and what can be
done to
address the causes?’” Ornish notes the he and others have shown that
a variety
of lifestyle changes can reduce chronic inflammation. Ornish then adds the
kicker outcome of
health-oriented, lifestyle interventions: “The only side effects of
comprehensive
lifestyle changes are good ones.” Ornish's letter was re-printed here
in the Huffington Post.
 Magazine honors Bravewell trio
Page 108 of the April 2010 edition of Vanity Fair includes a
photo of the 3 women who have led the Bravewell Collaborative: Christy
Mack, current president, Penny George, founding president, and Diane
Niemann, executive director. According to readers who saw the article,
the 3 women are featured in designer raincoats in a section entitled
"Hall of Fame." Mehmet
Oz, MD offered what one reader called "a fine nominating
statement." Oz nominated them for their role in advancing integrative
medicine.
Comment: The question of the day is:
Which most advances integrative medicine: a) the New York Times'
inclusion of the
approach as a doctor-recommended cost-saving solution? (see related article under "Cost" in this
Round-up); or b), this
Bravewell trio being highlighted in Vanity Fair?
Internet videos, radio on
integrative practice
Recently a number of integrative practice interests sent links to
videos related to their work.
Portland Tribune offers pro-con feature on growing use of naturopathic doctors as primary care in Oregon
"Paging Dr. Alternative: State pushing naturopaths to fill shortage in primary care" is the title of the April 2, 2010 article in the Oregon-based Portland Tribune. The article offers a portrait of the emerging use of naturopathic physicians as primary care practitioners in the state. A chart from the article, below, points out that the state has more naturopathic doctors per person than any other state.
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