Summary: IOM Committee on Advancing Pain Research, Care and Education includes Rick Marinelli, ND, LAc and integrative MD Lonnie Zeltzer ... Did integrative practice organizations step up to participate in federal policy comment periods on prevention, benefits plans and ACOs? ... Comparative cost analysis of Blue Cross Blue Shield Tennessee low back pain data finds 20%-40% savings via using chiropractors first ... Spine comparative effectiveness analysis also thumbs up for chiropractors ... Primer on strategies for cost analysis of "CAM" published ... World Health Organization publishes benchmarks for training TCM, NDs, DOs, others ... Certified Professional Midwives push for Medicaid inclusion ... Mark McKenzie, LAc offers "progress report" for AOM field ... George Lundberg column shows battle over independent practice by non-MDs ... Samueli Institute in major wellness role at Big Task Weekend ... Alliance for Massage Therapy Educators publishes results of survey on standards ... AANP exec Karen Howard lays out federal priorities for naturopathic doctors ... AHRQ-publishes report that finds only modest value for CAM in back/neck pain ... Little headway in battle against medical errors, medical deaths ... Massage researcher Tracy Walton offers candid comment when major integrative pediatrics trials comes up negative ... Fox Business pumps integrative medicine ... AMA board chair Ardis Hoven, MD promotes interprofessional collaboration, with MDs in the center ... Walgreens seeks to "own 'well'" ... Barrie Cassileth's International Integrative Medicine conference ... Integrative Healthcare Symposium likely to draw over 1500 in New York ... Peter D'Adamo's Institute for Human Individuality to focus on "Generative Medicine" at May 2011 meeting ... Vanessa Esteves takes position with Elements Wellness.

Policy

Marinelli: IOM appointment a first for NDs, LAcs

IOM Pain Committee includes integrative MD Lonnie Zeltzer and Rick Marinelli, ND, LAc

The Institute of Medicine (IOM) Committee on Advancing Pain Research, Care and Education, named in November 2010, includes two practitioners of integrative medicine. Portland, Oregon-based clinician Rick Marinelli, ND, LAc, is the immediate past-president of the American Academy of Pain Management and a gubernatorial appointee to the Oregon Pain Commission. Lonnie Zeltzer, MD, is an integrative pediatrician and researcher associated with the UCLA Collaborative on Integrative Medicine, a member of the Consortium of Academic Health Centers for Integrative Medicine.

Zelzer: Integrative pediatrician also selected

Comment: Fascinating convergence of interest here. First, millions of citizens are using chiropractic doctors, massage therapists, acupuncturists, mind-body practices, holistic nurses, integrative medical doctors and naturopathic doctors for pain conditions. Second, the proposed 2011-2015 NIH NCCAM Strategic Plan states that a key "area of promise and need" is in treating chronic pain. Third, unintended consequences of the JCAHO Pain Management Standards adopted in 1999 have stimulated a growing crisis in cost and care. (Interestingly, the JCAHO standards that fostered vast expansion of parma-based pain relief were also an early inclusion of CAM in a significant mainstream document. The JCAHO pain standards included reference to complementary healthcare practices under "non-pharmacological" treatment options.)

Good for the IOM to recognize, in the appointments of Marinelli and Zeltzer, the potential for contributions from the complementary, alternative and integrative practice communities in developing optimal treatment strategies. What if the national strategy actually elevated integrative approaches toward the front-line rather than burying them as after thoughts? Will this IOM national strategy be remembered as the time when the optimizing use of "non-pharmacological" approaches will help us break our pattern of growing pain pill addiction?

Surgeon General Benjamin: Seeking input on prevention strategy

Federal comment periods open, close on health reform initiatives: Are integrative practice interests showing up?

Opportunities to have a say in 3 important new federal health initiatives following passage of the Obama-Pelosi Affordable Care Act opened and closed in November/early December. The US Surgeon General Regina Benjamin, MD, MBA called for comments on an emerging "framework" to guide the work of the National Prevention and Health Promotion Council. (The first 4 duties of this council directly reference "integrative health care," making this a quality opportunity to participate.) An Institute of Medicine study on Essential Health Benefits had a short comment period in early December. The IOM study will create guidelines for what's in and out of coverage with the 2014 implementation date for the new healthcare law. Finally, the Center for Medicare and Medicaid services offered a comment period that expired on December 3, 2010 on Accountable Care Organizations

Comment: I corresponded recently with an Integrator reader who works inside a large federal healthcare agency. The reader noted that most people probably don't realize how much agencies do, in fact, pay attention to comments. That said, it does not appear that the integrative practice fields, as individuals or organizations, have stepped up significantly to be heard. Sadly, this is despite the fact that hard work from integrative practice-related interests actually placed language about integrative health care in at least one of the laws (Prevention Council) on which the comment period was recently open.

Credit the Samueli Institute's Wayne Jonas, MD and Brian Thiel for a response which I will publish later this month in the Integrator. Samueli was instrumental in getting the "integrative healthcare" language in the prevention and health promotion section of the law. Credit also former policy wonk Bob Benson, founder of the Association of Bodywork and Massage Professionals, for contracting with Diana Thompson, LMP, immediate past-president of the Massage Therapy Foundation, for an excellent submission ABMP posted here. I have also heard from a couple of other individuals who participated.

Perhaps more organizations and individuals have commented but simply not shared their input. Bottom line, if the dozens of institutions and organizations associated with the integrative practice fields don't show up, we lose a chance to make a difference. The community also loses rights to complain about being left out. It's a shame to have opened doors, in the prevention arena, and then, it appears, only barely walked through. Too bad, especially, given the claims of virtually all integrative practitioners and organizations that their fields have a special relationship to prevention, health promotion and wellness. We may simply not be ready for prime time. (Thanks to Claire Johnson, DC, Taylor Walsh, and Molly Punzo, MD for alerting me to these opportunities to participate, which I passed on to Integrator readers and, in the case of the prevention-related opportunity, to Integrative Practitioner readers.)

Cost of Care

Major savings from care management by chiropractors

Examination of Tennessee Blue Cross Blue Shield data finds 20%-40% lower costs for LBP patients who see chiropractors first

"Starting with Chiropractic Saves 40% on Low Back Pain Care." So runs the headline in a November 16, 2010 release from the American Chiropractic Association (ACA). The study itself, by a team that includes well-known health services researchers Michael Finch, PhD and Christine Goertz, DC, PhD, carries a less effusive title: Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer.

• "For low back pain, care initiated with a chiropractor (DC) is less costly than care initiated through a Medical Doctor (MD). Paid costs for episodes of care initiated with a DC are almost 40% less then episodes initiated with an MD.
  
  
• "Even after risk adjusting each patient's costs we found that episodes of care initiated with a DC are 20% less expensive than episodes initiated with an MD."
  

McMichael: Savings attributed to DCs' more conservative approach

The analysis, carried out in 2006, was funded through a grant from the ACA. ACA president Rick McMichael, DC, shared with the Integrator that "we think this is a very strong study, with major implications." He attributes the outcomes to chiropractic medicine's "more conservative approach" and how chiropractors "get in there and partner with patients" to move them toward health. The study, says McMichael,

Comment: At the time of my interview with McMichael, the study had not yet produced or received much mainstream media attention, other than this online Medical News link. I am reminded of comments by integrative cardiology researcher Eileen Stuart, RN, MS, PhD, regarding the reception of her scientific offerings at cardiology meetings. Stuart's research, published in top journals, had found significant benefits of a program she developed at Harvard with Herbert Benson, MD that combined natural health measures for heart patients: "I always have a few doctors come up after and ask about the program. If these outcomes had been due to a drug, the doctors would have been flocking around me."

Imagine what kind of media coverage we would see from a press release like this: "New drug shown to save 20%-40% on treatment of conditions that costs nation $50-billion annually." It doesn't help that ACA was the study's backer, suggesting potential bias. Yet one wouldn't think BCBS Tennessee would be interested in scamming the public on behalf of chiropractors. Better dead than red, I guess. Drug medicine uber alles.

" ... compared to family physician-directed usual care, full clinical practice guideline-based treatment including chiropractic spinal musculo-therapy treatment is associated with significantly greater improvement in condition-specific functioning." 

Comment: The same journal recently published an analysis in South Korea of collaborative care for low back pain using acupuncture, using a "Markov model." The authors concluded that "acupuncture collaborative therapy for patients with chronic LBP may be cost-effective if the usual threshold is applied. Further empirical studies are required to overcome the limitations of uncertainties and improve the precision of the results." (Thanks to Mitchell Stargrove, ND, LAc for the heads-up on the evaluation paper.)

World Health Organization

WHO publishes documents on benchmarking training for TCM, naturopathy, Ayurveda, others

• "Support countries in establishing systems for the qualification, accreditation or licensing of practitioners of traditional medicine;
• "Support countries in establishing systems for the qualification, accreditation or licensing of practitioners of traditional medicine;
• "Facilitate better communication between providers of conventional and traditional care, as well as other health professionals, medical students and relevant researchers, through appropriate training programmes;
• "Support integration of traditional medicine into the national health system."

The lead agency in the effort, which also drove the successful 2009-2010 lobbying, is the MAMA Campaign, involving all the field's national organizations. The campaign's website features a fetching video on the midwifery field. A notice from the organization stated that the new bill was to be introduced the week of November 29, 2010.

McKenzie: Celebrating new collaboration, urging new participation

"Progress Report" on the acupuncture profession from education-accreditation leader Mark McKenzie, LAc

Individuals interested in a quick look inside the acupuncture and Oriental medicine (AOM) profession may find it useful taking a couple minutes with the Progress Report

Lundberg: Mixed messages in controversial audio column

Comment: Of more interest than Lundberg's confusing remarks (he appears to be in an early stage of the change process in realizing it is time to shake the pernicious influence of guild) are the extensive comments his commentary provoked. One actually experiences the unleashed wave of nursing energy sweeping away the guild barriers to improvement that have held MDs in power. The Robert Wood Johnson Foundation-funded IOM study has called the question on MD control of US healthcare. The battle is unfolding. It's worth close tracking for all fields that are interested in expanding recognition and independent practice.  (Thanks to reader Mary Jo Kreitzer, RN, PhD for sending the link.)

Collaboration effort leans on Samueli Institute for wellness project

Samueli Institute co-chairs the health and wellness group at "Big Task Weekend"

Alliance moves stepwise into needed role for massage educators

Alliance for Massage Therapy Education publishes results of educational standards survey

• "82.0% agreed that national standards need to be established for massage/bodywork curricula in entry-level programs, versus 7.1% who disagreed.
• "80.4% agreed that competency-based national teacher education standards are needed, versus 6.8% who disagreed.
• "75.3% agreed that there needs to be national standards defined for advanced-level training programs and certification in specialized areas of practice, versus 11.2% who disagreed.
• "53.5% indicated their agreement with the need for a single centralized approval program for continuing education providers and courses, versus 25.6% who did not agree that such a program was needed.
• "53.2% agreed that the Massage Therapy Body of Knowledge needs modification before being adopted as an "official" document to be used by state agencies and national accrediting commissions, versus only 5.2% who disagreed."

The release concludes: "This data affirms the strategic direction established by the Alliance, and is congruent with one of the organization's key goals: to develop standards that guide and inform the effective teaching of massage therapy." (A guest column by Alliance executive director Rick Rosen, LMBT on the role of the organization is here.)

Schwartz: Will other massage organizations collaborate?

Comment: I asked Integrator editorial adviser Jan Schwartz, MA, past president of the Commission on Massage Therapy Accreditation, and co-founder of Education and Training Solutions, for her response. Schwartz wrote:

"I don't think these findings surprise anyone. The trick with massage therapy education is to make something happen on a national level. There are 1500 schools, 50 states and plus or minus 250,000 therapists in the U.S., so it's like turning a battle ship, not a kayak. (I hate to use war like imagery, but in this case it's appropriate!)  My hope is that the other organizations in the massage therapy field will be willing to work with the Alliance to move this progressive agenda forward."

Howard: AANP exec lists federal priorities for NDs

AANP's executive director Karen Howard announces policy priorities for naturopathic profession

• "Defining key terms from the law, including 'integrative healthcare practitioner' and 'nondiscrimination,' by working with the Department of Health and Human Services and the Senate. Since Democrats retained control of the Senate, health and wellness champions can continue to play a central role in the regulatory and funding process.
• "Funding of a new Public Health Workforce Loan Repayment Program authorized in the new law.  We have been advised that NDs will qualify to participate, if and when the program is funded.
• "Working for inclusion of NDs in all existing federal loan repayment programs, a collaborative effort of AANP and state affiliates working with both federal and state legislators and regulators.
• "Using our relationships with coalitions and others to expand access to naturopathic care at the state level by supporting licensure and expansion of scope, focusing on saving cash-strapped states healthcare dollars."

Agency publishes Canadian EBM review

AHRQ publishes evidence report showing

"Evidence was of poor to moderate grade and most of it pertained to chronic nonspecific pain, making it difficult to draw more definitive conclusions regarding benefits and harms of CAM therapies in subjects with acute/subacute, mixed, or unknown duration of pain. The benefit of CAM treatments was mostly evident immediately or shortly after the end of the treatment and then faded with time. Very few studies reported long-term outcomes. There was insufficient data to explore subgroup effects. The trial results were inconsistent due probably to methodological and clinical diversity, thereby limiting the extent of quantitative synthesis and complicating interpretation of trial results. Strong efforts are warranted to improve the conduct methodology and reporting quality of primary studies of CAM therapies. Future well powered head to head comparisons of CAM treatments and trials comparing CAM to widely used active treatments that report on all clinically relevant outcomes are needed to draw better conclusions." (bold added)

, and the importance of pain in the emerging 2011-2015 NCCAM strategic plan.

IOM publication in 2000 found 98,000 annual deaths from medical errors

Major reports show efforts to limits medical errors and medical deaths are coming up short

"Efforts to make hospitals safer for patients are falling short, researchers report in the first large study in a decade to analyze harm from medical care and to track it over time." The November 24, 2010 New York Times article based on research in North Carolina is boldly head-lined Study Finds No Progress in Patient Safety in Hospitals.

" ... examined 2,300 randomly selected patients' records at 10 hospitals in North Carolina from 2002-2007 and found 588 instances of 'patient harm,' including surgical errors, hospital falls, misdiagnoses, medication errors, and hospital-acquired infections. Fifty of the incidents were considered life threatening, and 14 people died, according to the study."

Comment: It's been 11 years since the IOM appropriated Alexander Pope's poetic phrase To Err is Human as a title for their landmark, eye-opening study that concluded that at least 98,000 hospital deaths each year come via medical errors. Much effort was put into responding, particularly under the leadership of Don Berwick, MD, who led the 100,000 Lives Campaign through the Institute for Health Improvement. Berwick is now Center for Medicare and Medicaid Services administrator. (The findings are not likely to help Berwick with his vociferous opponents on the Hill since his efforts could be framed as failures.) Interestingly, Pope's full phrase is that "to err is human, to forgive is divine." When it comes to medical errors, I suspect that most of us remain located in different panels of the usual and customary triptych.

Walton: Honest look at challenging outcomes

Massage researcher Tracy Walton offers transparent response to surprisingly poor outcomes for pediatric massage in major study

What do you do when research doesn't come out the way you'd like? Massage research leader and oncology massage specialist Tracy Walton, LMT, MS provides an unusually candid commentary on the topic. Walton heard researchers at the American Massage Therapy Association conference report findings of a large, NIH-funded, controlled trial of massage and humor for children with stem cell transplant. Walton's summary in a Massage Today article includes this statement: "The study reported that massage had no effect on any of the outcomes studied. Not one." Walton offers a quality reflection on how she digested findings that surprised even the researchers.

Comment: Kudos to Walton for the unusually candid response. Interestingly however, she concludes with this: "I am not ready to abandon massage of stem cell therapy patients, nor do the investigators suggest that we should." 

Media

Article positive on integrative medicine

Fox Business anoints integrative medicine

"Integrative medicine may be just what the doctor ordered" is the title of the November 19, 2010 article in Fox Business. The article references programs at Harvard, Duke, Atlantic Health Systems, and elsewhere. The author providess a generally positive review, with one quote from a nay-sayer. About the Atlantic integrative medicine program, the author writes:

"Meanwhile, in New Jersey, Atlantic Health System is also democratizing IM at its four residential community locations. 'We knew we were making strides when we received the recognition and support of our cardiac surgery team, who acknowledged that their patients were getting relief,' says Emilie Rowan, manager of integrative health at Atlantic Health. 'The docs started to refer patients to us.'"

Hoven: AMA chair urges MD-centric collaboration

AMA leader stresses value of "physician-directed" inter-professional collaboration

American Medical Association board of trustees chair Ardis D. Hoven, MD, an internist from Lexington, Kentucky, recently weighed in on the importance of interprofessional collaboration. The title of her AMA Leader Commentary in American Medical News on October 18, 2010 was "Quality care follows when health professionals collaborate."

"When each one is an expert in his or her own field and all are trained to work toward a mutual goal, individual contributions are magnified, and results are more than a single person could ever achieve."

Comment: Hoven's column was circulated to me by colleagues promoting inter-professional education as a means of creating mutual respect and understanding between the disciplines. Most were excited to see this apparent openness from the top of the AMA. The willingness to consider teamwork, and acknowledge a need to work on it, is a step in the right direction. But there is clearly no room here for chiropractors, nurses, naturopathic doctors, AOM professionals or any non-MD to be leaders of the collaborative teams. The extraordinary Blue Cross Blue Shield of Tennessee data showing 20%-40% cost-savings when patients first access chiropractors, and reported in this Round-up, is one example of the value that may not be accrued by our health system unless we allow other practitioner types as team leaders. The Institute of Medicine's report on the future of nursing makes the case for hte importance of nurse-led teams. The era of collaboration in US medicine may actually begin only after MDs let go of their belief in their necessary centrality.  No one likes playing with anyone who says it's my ball, so collaborate by my rules, especially when evidence to support ball-taking is scant. Wouldn't it be nice if the AMA decided it was time for a Tai chi move, rather than Western pugilism? Might the AMA lead best by empowering others to leadership?

Cassileth: Heads up European integrative conference

International Integrative Care for the Future, Amsterdam, March 11-12, 2011.

Conference and multi-disciplinary community gathering likely to draw at least 1500

Integrative Healthcare Symposium, New York City, March 4-6, 2011

In 2011 Integrative Healthcare Symposium (IHS) is anticipated to draw even more participants that the 1200+ who attended the 2010 multi-disciplinary event. At the IHS, MDs, nurses, chiropractic doctors, nutritionists, naturopathic physicians and others gather at the New York Hilton for 3 days of top flight content from integrative practice leaders. The continuously growing conference has become the premier annual event of its kind. The sterling line-up of speakers includes Rachel Remen, Jeff Bland,

Comment & Alignment of Interest:  This conference has morphed from being not only an exceptional meeting for clinicians but also a significant community gathering. I will be involved in 2 presentations related to policy and practice, as part of my role with Integrator sponsor IntegrativePractitioners/IHS. One is a review of the year's developments in integrative healthcare policy, with Erik Goldman, editor of Holistic Primary Care. The other is a panel I will moderate on in-patient integration programs with an exceptional trio of experts: Knutson (Allina Hospitals & Clinics), Ben Kligler, MD, MPH (Beth Israel) and Richard Gannotta, NP, DHA (Duke) whose survey on inpatient programs is reported here. Make it if you can!

Peter D'Adamo's IfHI Generative Medicine conference, May 20-22, 2011

The Institute for Human Individuality, founded by naturopathic clinician and author Peter D'Adamo, ND will host its 6th conference May 20-22, 2011 in Norwalk, Connecticut. The focus will be on what D'Adamo, known for his writing on blood type diets, calls "generative medicine." In

Comment: In a phone call and email exchange about his work and about complexity issues in integrative healthcare research, I shared with D'Adamo the recently published paper on complexity science that grew out of a 2007 NIH NCCAM-funded invitational gathering convened by Adi Haramati, PhD. The topic: Applying Principles from Complex Systems to Studying the Efficacy of CAM Therapies. D'Adamo, a colleague of 20+ years, shared a few comments about the publication and then suggested the following as a statement to run with this Integrator notice on his conference:

"The problem with analyzing naturopathic therapies is that most researchers see them as complex entities working in simple relationships. Reality is more often the exact opposite of this."

One is guaranteed complexity at D'Adamo's events, not always simple resolutions.

People

Esteves: new position at Elements Wellness

Esteves named director of corporate health programs for Elements Wellness