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Medicial Mistakes?
How many people each year suffer some type of preventable harm that contributes to their death after a hospital visit?
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| | Integrative Medicine and Integrated Health Care Round-up #37: November 2010 | |
Summary: Flurry of opposition to AMA ownership of CPT codes amidst report of AMA's $70-million of annual royalties ... Center for Public Integrity reports "secretive" AMA committee that guides Medicare priorities on billions of dollars ... AAAOM, CRN, ACCAHC, NPRI and AHMA in follow-up statements on NIH NCCAM strategic plan ... Update on Integrated Healthcare Policy Consortium federal action for integrated health care: PCORI and workforce issues ... "Mother of holistic medicine" Gladys McGarey, MD takes on changing federal policy, at age 90 ... True North Center turns SmartMoney lemons into lemonade ... Guarneri-led Bravewell team publishes pamphlet on cost-effectiveness of integrative medicine ... Multidisciplinary effort led by Harvard's Marilyn Moore and U Minnesota's Karen Lawson, MD moves to set national health coaching standards ... Massage certification group NCBTMB sets stage to offer advance practice certification program ... ACA part of Sharecare internet play that includes Mehmet Oz, MD, Dean Ornish, MD and nursing groups ... A call to "put integrity into integration" from Daniel Redwood, DC ... Report leads to reconsideration of whether some placebos were placebos ... Huffington Post expands its integrative medicine-focused health portal ... Michael Cohen in new law firm ... Charles DuBois honored ... Lori Knutson, RN in expanded role ... Chris Ellis takes helm at AAAOM ... Shelly Johnson new interim director role at American Massage Therapy Association.
Policy
 CPT royalties a bonanza for AMA
A recent report in the Integrator
revealed that the political work of the American Medical Association
(AMA) is subsidized to the tune of roughly $70-million each year through
royalties from its ownership of Current Procedural Technology codes
(CPT). Providers from all disciplines who accept 3rd party payment
effectively pay into this AMA fund, despite the fact that the AMA
opposes the advances of other disciplines, especially as
independent practitioners. The Integrator report was prompted by concerns of integrative nursing leader Mary Jo Kreitzer, RN, PhD on learning that
the AMA had immediately opposed the independent practice for nurses
recommended in the long-awaited October 5, 2010 Institute of Medicine
(IOM) report entitled
The Future of Nursing: Leading Change, Advancing Health. A multidisciplinary
IOM team presented the vision of a future in which nurses, without MD supervision,
will provide a significant portion of the nation's primary care. Nursing
supporters welcomed the study as opening a "golden age of nursing." The AMA immediately opposed this core recommendation.
 The IOM report on nursing, opposed by the AMA
Comment: It is an astonishing confrontation with the past to imagine that such power was ever conferred on a single guild. The necessary transformation of US healthcare
is toward diversity, multidisciplinary practice, collaboration, team-care, and
respect for the skills of all parties. The movement is away from the still current MD-centric, patriarchal,
top-down, father-knows-best world of Dr. Kildare. The response to the Integrator article has been, bluntly put, that enough is enough. (See 18 Views: Forum on the AMA's $70-million CPT Warchest Includes Calls for Action to End the Subsidy.) Says integrative nurse Kreitzer: "Let's end it.
Center for Public Integrity research reports AMA's "secretive" control of Medicare payments
The October 26, 2010 story in the Wall Street Journal is entitled Physician Panel Prescribes the Fees Paid by Medicare. It begins this way:
"Three times a year, 29 doctors gather around a table in a hotel meeting
room. Their job is an unusual one: divvying up billions of Medicare
dollars. The group, convened by the American Medical Association, has no official
government standing. Members are mostly selected by medical-specialty
trade groups. Anyone who attends its meetings must sign a
confidentiality agreement."
The WSJ article is based on work at the Center for Public Integrity. The article refers to the AMA's panel, the Relative Value Update Committee (RUC),
as "secretive" and to the group's power as "enormous." The Centers for Medicare and
Medicaid Services typically follow 90% of the RUC recommendations. The panel is
viewed as hampering reform efforts. A key area: resistance to moving resources
toward generalists and primary care. Says former CMS administrator Tom
Scully of the AMA's role: "It's indefensible. It's not healthy to have the interested party essentially driving the
decision-making process."
Comment: Anyone wonder whether these old
structures - CPT and RUC - might be getting in the way of reform? These two
stories, both published October 26, 2010, are quite a pairing. The best comment on both is this reflection,
relative to the CPT issue, from Lori Knutson, RN, BS-HN, director of integrative health care for
Allina Hospitals & Clinics and the Penny George Institute for Health and Healing. Knutson writes here:
"Kudo's for
bringing awareness to the presenting problem of the AMA/CPT code
'energy block' that has somehow covertly managed to stay quite hidden
in the meridians of our dis-eased healthcare system. Our ability to
move
this very important work forward does, at times, require exposing and
experiencing the hidden devices of underlying cause. Sometimes
debriding
is the right medicine. I am sure that as the uprooting of our
healthcare
system unfolds there will be more surprises (learning's?). Hopefully
we
have come to a point in our society that we realize its time to come
together,
let go, and remember "We the People" created this and "We the
People" are obligated to make it right for the whole.
 Comments on draft 2011-2015 strategic plan
The now year-long process of public commentary and response on the development of the 2011-2015 strategic plan of the NIH National Center for Complementary and Alternative Medicine recently stimulated a new round of responses from key stakeholders. Published here
are letters from the American Association of Acupuncture and Oriental
Medicine, Council for Responsible Nutrition, Academic Consortium for
Complementary and Alternative Health Care and the Naturopathic
Physicians Research Institute. A perspective of David Forbes, MD,
president of the American Holistic Medical Association is here.
The most significant common response is to honor NCCAM for
prioritization of "real world research" and the health-promoting
outcomes of
integrative interventions, but also to urge that this focus be elevated.
Disclosure: I was involved in drafting the ACCAHC letter.
 IHPC's Kahn: Advancing policy opportunities
The Integrated
Healthcare Policy Consortium, directed by Janet Kahn, PhD, has moved
forward in two areas since the September 27-29, 2010 policy conference on
strategy to follow-up on the advances that "integrative practices,"
"integrative practitioners" and "licensed complementary and
alternative medicine providers" gained in the Patient Protection and Affordable health Care
Act (PPACA). The conference was co-hosted by IHPC, Palmer College of
Chiropractic and the Institute for Integrative Health. IHPC engaged leaders of
a Health Resources Services Administration committee on shortage areas to
educate them about the integrative practice fields, especially to provide
information about disciplines that are considered part of the primary care
matrix in some states, but are not typically included in federal programs. A
focus in the IHPC's October 4, 2010 letter was inclusion by the states of Vermont and Washington
of certified professional midwives and naturopathic physicians.
In addition,
IHPC, working with recommendations made by a conference work group on the Patient Centered Outcomes
Research Institute (PCORI) and others, nominated three researchers for the PCORI Methodology Committee. Among PCORI's charges are exploring
integrative practices and including integrative practitioners in their
leadership. Nominations were closed October 31, 2010. In between these
activities, Daniel Redwood, DC and Kahn are working on the report from the
conference. The Integrator will alert you when that is available.
 McGarey: Taking on reform at 90
Gladys T McGarey, MD is known to many as a founder of holistic medicine.
In recent years, she has twice convened gatherings of holistic medical
leaders, through the Gladys Taylor McGarey Medical Foundation, to explore strategies to shift the paradigm of US medicine. The 2010 report
is based on 2 days of work by a selected group of 60 "holistic
physicians, nurses, medical researchers and other integrative
providers." The recommendations in the report range from promoting
wellness, supporting holistic pregnancy and birth, standardizing
certification and licensing, and funding education and research
strategies. The recommendations covered a broad arena, from changing conventional medical
education to increasing research and practice and providing support for distinct fields such as
naturopathic and homeopathic medicine. One unusual recommendation: "Recognizing
Women as Important Healthcare Decision Makers." The report notes that women are
estimated to make 80% of healthcare decisions.
McGarey, energetic at 90-years-old, is making a series of visits to healthcare leaders
in the Beltway in an attempt to foster the shift for which she has worked for decades. The reports from the 2009 Gathering of Eagles
as well as those from the June 2010 meeting are anchored to President Obama's call for
reform. One target: educating administrator Donald Berwick, MD and the Centers for Medicare and
Medicaid Services about the value of integrative approaches.
Comment: A colleague from a decade ago,
Terry Schmidt, DHA,
linked me into the work of McGarey's team. McGarey's energy is
enviable. I urged her team to appreciate that some terrific coalition
work is
underway -especially that noted above through the Integrated Healthcare
Policy Consortium, Samueli
Institute, The Institute for Integrative Health and the Palmer Center
for Chiropractic Research. Hopefully McGarey's eagles will find ways to
have their work dovetail with that of these organizations so power can
begin to coalesce and who knows,
perhaps prove effective!
Integrative Centers
 Article poorly portrays True North center
Maine's True North Healing Center recently sent out a press release following coverage of the clinic's method of care in an article entitled Medicine without Doctors in Wall Street Journal's SmartMoney.
Rather than merely boasting the coverage, True North used the moment to
describe the chasm between the media presentation which had left some false impressions and what actually
takes place in True North's integrative practice. For starters, the clinic boast both medical and
naturopathic medical doctors. The release also educates about the functional medicine approach that both use, and the science behind Peggy Huddleston's Prepare for Surgery, Heal Fast Program. In the account by the WSJ writer, "alternative medicine" was first discounted then the author chose to focus on a specific agent, a
"bacteria-filled supplement supplied by the center."
Comment: Funny, the WSJ writer
started her "alternative medicine" bit that featured True North with 4
sentences discounting any evidence for such care, then proceeded to
write an article which apparently was not evidence-based journalism.
Credit True North for taking the lemons and making lemonade.
Cost Effectiveness
 Guarneri: Headed Bravewell team on cost report
The Bravewell Collaborative of philanthropists for integrative medicine has published a new 16-page pamphlet entitled The Efficacy and Cost-Effectiveness of Integrative Medicine: A Review of the Medical Literature.
The authors are: Ermenia (Mimi) Guarneri, MD, Scripps Center for
Integrative Medicine, Scripps Health; Bonnie J Horrigan, Bravewell's
director of communications and public education; and Constance M
Pechura, PhD, executive director of the Treatment Research Institute (TRI). The authors begin by indicating that
"A review of the medical, corporate and payer literature reveals that, to start, immediate and significant health benefits and cost savings could be realized throughout our health care system by utilizing three integrative strategies:
- Integrative lifestyle change programs for those with chronic disease;
- Integrative interventions for people experiencing depression; and
- Integrative preventive strategies to support wellness in all."
Comment: This pamphlet is a conservative
presentation of the economic value of "integrative medicine." The
authors focus on the work of Dean Ornish in reversing atherosclerosis,
mind body stress reduction programs of Jon Kabat-Zinn with
depression, and corporate wellness programs. Not included are most of
the studies referenced by economist-researcher Patrica Herman, MD, ND,
PhD in her Systematic Review Yields Top 9 Therapies/21 Conditions with High Quality Evidence of Cost Savings from CAM.
Not mentioned anywhere in the Bravewell presentation are any outcomes
relative to practices by practitioners of massage, acupuncture,
chiropractic, yoga therapy, naturopathic medicine or dietary
supplements. (See, for instance: Analysis of Washington insurer data finds CAM-using
insureds have lower expenditures than non-users.) Still, this little booklet, downloadable here, should prove useful in some environments.
Professions
 Moore: Co-chairing effort to set health coaching standards
"Health and wellness coaching is the change agent that shifts the
culture and delivery of health care from dependency to empowerment." So
reads an aspirational poster
from one of the working groups at the late September summit to explore
national standards and certification in the field of health and
wellness coaching. In an October 20, 2010 release from the organizers, Pamela Peeke, MD, an adviser to US Surgeon General Regina Benjamin, MD, MPH is quoted as saying:
"Health and wellness coaches will play an integral role in the
prevention portion of healthcare reform legislation - they will help
catalyze a transformation in healthcare."
The chairs of the meeting were Margaret Moore, co-director of Harvard's Institute of Coaching and CEO of Wellcoaches Corporation, and long-time integrative and holistic medicine leader Karen Lawson, MD,
director of health coaching at the University of Minnesota Center for
Spirituality and Healing. A multidisciplinary group of 70 individuals
attended. An issue that prompted the
organizers is that "presently 'health coach' and 'wellness coach' can be
used by anyone, whether or not they have completed coach training
designed for health and wellness coaches." In addition, training
programs that exist are of varying lengths. An organizing team is
expected to continue taking steps toward the inter-related goals of
setting standards, creating credentialing and building a professional
organization. A report from attendee Jennifer Johnson, ND is here.
Comment: Coaching, different than "education" or "counseling," deserves an elevated role in integrative practice. I shared my views on this subject in With Standards in the Works, Is it Time to Claim, and Certify, the Health Coach Within? My perspective is not unanimously embraced. (See Chris Johnson, ND: "Disturbed" by the Positive View of Health Coaching in Integrative Practice.) Still, I believe that all integrative practitioners who claim that they help empower people have skin in this game.
 NCBTMB's advanced certification seal
On October 8, 2010, the National Certification Board for Therapeutic Massage & Bodywork (NCBTMB) announced "continued progress" in developing its exam for the National Certification for Advanced Practice (NCAP).
NCBTMB presents the initiative as "the first to enable accomplished
(massage) practitioners to differentiate themselves in the massage
marketplace." The agency suggest that the certification will also "make
it possible for employers and members of the conventional and
integrative healthcare arenas to hire practitioners based on a
certified, advanced level of experience and expertise." "NCBTMB Chair Neal Delaporta
is quoted saying that "the credential will open up new opportunities
for therapists in conventional, integrative and clinical healthcare
settings. It has the potential to take the entire profession to a new
level within the medical community."
Comment: The idea of advanced
certification has been floating around the massage community for some
time. I asked 2 massage educator colleagues from the Academic Consortium for Complementary and Alternative Health Care (ACCAHC) for their perspectives. Jan Schwartz, MA, past chair of the Commission on Massage Therapy Accreditation, and an Integrator adviser writes:
 Schwartz: Raises questions
"I would have preferred to see exams that were more population-based (for the lack of
a better term) in terms of techniques, knowledge, critical thinking
skills, etc. For example, oncology massage requires more than what people
get in massage school. Injury rehab and management requires more than
what people get in massage school. Same with pregnancy massage. If
I understand the new exam correctly, and Whitney (Lowe, LMT) can correct me if I'm wrong,
this is a generalized advanced certification (and I don't know what that
means).
"Also the survey that goes out for the job task analysis will probably go to
therapists who primarily graduated from 500 hour schools. How does that
say what is needed for an advanced certification? I'm simplifying here,
because others will no doubt complete the survey too, but you get the idea.
"I think they jumped into this without doing enough of the foundational work,
but I could be wrong about that too."
 Lowe: Chose to withdraw from NCBTMB team
"I would concur with
everything Jan has said here. I was on the task force that was working on this
exam for a short time, but I resigned in protest due to the way in which I felt
they were rushing the exam development process and not addressing key psychometric
issues.
"The problem stems from an attempt to address a key need in our field
(the ability to distinguish a massage therapist with basic knowledge from one
with more advanced skills).
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"[The offering] is also influenced by the
NCBTMB's need for this exam to generate
significant revenue because they are
losing their primary revenue stream
with their existing entry-level credential."
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"However, it is also unfortunately influenced by the
NCBTMB's need for this exam to generate significant revenue because they are
losing their primary revenue stream with their existing entry-level credential.
This has led to a number of serious errors (which Jan has mentioned) in the
exam development process and subsequently this also threatens the validity of
the exam. (Another issue is that
many in our profession don't understand basic principles of psychometric
validity so they don't see the disconnect behind these concerns.)"
The loss of income to which Lowe refers is that a new Federation of State Massage Therapy Boards was created recently and offers an exam that is increasingly supplanting NCBTMB's certification as a route to licensing.
 Oz: Part of Sharecare content group
The
American Chiropractic Association (ACA) is one of
several content partners participating in Sharecare, a new internet site created
by entrepreneur Jeff Arnold together with Harpo Studios, HSW International, Sony Pictures
Television and Discovery Communications and Mehmet
Oz, MD. Arnold is credited as the originator of WebMD. A release from that ACA states:
"From ACA to the American
Red Cross, the American Diabetes Association, John's Hopkins Medicine, and
others, Sharecare is bringing together the top minds in health care to
provide consumers with multiple perspectives within a single Web site
dedicated to improving health. The site will arm patients with more
information about their health care options and empower them to make better
choices."
Sharecare is a new social media platform "designed to greatly simplify the search
for quality health care information." The ACA is a partner for chiropractic content. Donna Hill Howes, Sharecare's senior vice
president calls the partnership "a natural fit," adding: "By bringing together the full spectrum of health care
disciplines on an expert social QA platform to facilitate conversations about
health, Sharecare is creating an environment that will foster innovation
within the health care community. We are thrilled to feature the chiropractic
profession's perspective on health and wellness."
Comment: Sharecare is an "internet
play" with a world-wide vision and mission and with apparently some
significant financial backing. Howes, for instance, is a former deputy director of a Bill and Melida gates Foundation unit involved with global health campaigns. In the business press Arnold is described
as "the latest entrepreneur to test the potential of social networking." AOL founder Steve Case's Revolution Health is noted as a recent expensive failure. This is one to watch. The ACA has little risk.
Media
 Redwood: Looking at core principles
In a commentary in the premier issue of the peer-reviewed Focus on Integrative Health Care,
educator and writer Daniel Redwood, DC, lays out a case for his belief that "sustainable
integrative health care systems must identify and nurture beliefs and
behaviors that model health-affirming ideals, including
patient-centeredness, openness, pluralism, holism, preventive self-care,
harmony of action and belief, and minimalism." Redwood's piece is called Walking Our Talk: Putting the Integrity into Integration.
Redwood's perspective draws from principles for
integrative medicine lined out by Centers for Medicare and Medicaid
Services administrator Donald Berwick, MD. He also highlights the "4 Pillars (Integrative
collaborative care; Cultural competence; Clinical sensitivity;
Technological innovation) and 2 Guideposts (Increased services to the
underserved; Decrease the brain drain of healthcare professionals)" offered by integrative medicine clinician, policy activist and educator Len Wisneski, MD. Also cited by Redwood
are some principles for health care renewal developed in 2001 and cited in the report of the White House Commission on CAM Policy.
Comment: Taking
principles for granted is a dangerous business. Principles need tending, particularly if such tender shoots are to survive in the getting-and-spending, rough-and-tumble of capitalistic health care in the United States. My
close colleague Pamela Snider, ND calls this tending "operationalizing the soul"
of one's medicine/health care. Good for Redwood to focus in on this
intersection of principles and for Focus editor Cheryl Hawk, DC, PhD to highlight this topic in the journal's premier edition.
 Expands integrative medicine-oriented site
The immensely successful liberal-left Huffington Post has chosen to give more presence to its medicine and health content by moving it out of the "Living" section into its own space. The content is overseen by a Medical Review Board replete with integrative medicine leaders. Dean Ornish, MD serves as medical editor and homeopath, acupuncturist and nutritionist Patricia Fitzgerald, DHM, LAc, CCN
serves as "wellness editor." HuffPo boast over 40-million unique
visitors per month. The site's editorial line promotes integrative
medicine.
Side-note: Ornish's bio states
that he holds the Safeway Chair at Preventive Medicine Research
Institute. Safeway has been a leader in corporate wellness
modeling. Ornish and Safeway struck up a multifaceted relationship in 2005. (Thanks to Integrator adviser Jan Schwartz, MA for tipping me to the HuffPo story.)
 Study increases awareness that sometimes a placebo is not
A recent study in the Annals of Internal Medicine is leading some to
question the findings of a large body of scientific literature. The
reason is captured in the title of a related Los Angeles Times article: A placebo is a placebo is a placebo .. or maybe not, a new study suggests.
Noted as an example is the use of a lactose pill as a placebo in a
large trial which, due to the lactose intolerance in many people, is not inert. Thus, by potentially worsening the symportoms of those on "placebo," to tested agent could be read as more positive than it is. The conclusions may have
over-stated the drug's value compared to what was clearly an uncontrolled control. The original Annals article is entitled What's in Placebos? Who knows? Analysis of Randomized-Controlled Trials.
The authors discovered that only 8% of studies with pills disclosed the
nature of placebos (26% for injections). They recommended a policy of
full disclosure.
Comment: The
issue is of particular interest to the integrative practice fields
given that not at all inert "placebos" have been used as "sham"
acupuncture and manipulation - with outcomes that too often hit the
media as "no better than placebo" when both treatment and placebo may be
better than customary care.
People
 Michael Cohen, JD, MA
Integrative care author and attorney Michael Cohen
has joined the Fenton Nelson healthcare law practice in Los Angeles. Cohen
writes that he has "joined a stellar Los Angeles-based healthcare firm
and am continuing to represent CAM providers and entities within a
sophisticated, national health law practice." Cohen, formerly part of
the integrative medicine team at Harvard University, and most recently
located in the Bahamas, has written over 100 books and papers on the
maturing field. He continues to author the CAMLawBlog. A review of Cohen's Healing at the Borderland of Science and Religion is here in the Integrator.
 Charles DuBois
Charles C. DuBois, president of Standard Process Inc.,
was honored with an award from the Foundation for Chiropractic Progress for his dedication to chiropractic
profession. Kent S. Greenawalt, chairman and founder of the
Foundation stated: "Charlie and Standard Process are truly dedicated to
helping the Foundation generate positive press for the chiropractic
profession." Through Standard Process, DuBois committed more than $3
million to the chiropractic profession in 2009. DuBois also serves as a board
member for the Foundation. Standard Process was recently recognized as Wisconsin's 63rd largest firm.
 Chris Ellis
Management consultant Chris Ellis has taken over as executive director
of the American Association for Acupuncture and Oriental Medicine (AAAOM).
According to a notice from AAOM, Ellis "has worked closely with over fifty
organizations in both the for-profit and non-profit sectors, helping them to
improve their performance and value delivery." Ellis authored
The Enlightened Enterprise:
Walking the Path of the Conscious and High Performing Organization,
in which he "applies principles from Asian philosophical traditions to
create a
conceptual blueprint for the high performing enterprise of the future."
Ellis takes over for Rebekah Christensen who was honored by the AAAOM
for her role in "helping to facilitate the
AAOM/Alliance merger and led our profession into anew era of collaboration." Ellis
begins in a difficult moment for the organization, which has struggled
to gather membership from the nation's licensed acupuncturists.
 Lori Knutson, RN, BS-HN
Lori Knutson, RN, BS-HN, executive director for the Penny George Institute for Health and Healing at Allina Hospitals & Clinics notes that she has
"officially transitioned my role to lead
the Allina-wide Integrative Health Clinical Service Line as we are
officially moving this
work across Allina." The move is significant as Allina has 12 hospitals
in its system, plus an array of clinics and other facilities. Adds
Knutson: "We open our comprehensive
integrative oncology center in November and I am now working on a Whole
Family
Integrative Health Clinic in partnership with Minnesota Children's Hospitals &
Clinics IM group" led by Timothy Culbert, MD.
 Shelly Johnson
Shelly Johnson,
deputy director of the American Massage Therapy Association (AMTA) for 8
years, was appointed AMTA's interim executive director
in August 2010. Johnson has worked with associations for 22 years,
including the
American Society for Quality, the American Society of Neuroscience, the
American Board of Neuroscience Nursing, the Neuroscience
Nursing Foundation and the American Society for Healthcare Materials Management
of the American Hospital Association. Johnson replaces former executive Elizabeth Lucas in the position.
Send your comments to
[email protected]
for inclusion in a future Your Comments Forum.
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