Health Care Reform - No Progress

For those who oppose health care reform of any kind, you should reade the New Yorker article by Atul Gawande, one of the emeging great thinkers on the heathcare scene. He opens his article with the following:

Health-care costs are strangling our country. Medical care now absorbs eighteen per cent of every dollar we earn. Between 1999 and 2009, the average annual premium for employer-sponsored family insurance coverage rose from $5,800 to $13,400, and the average cost per Medicare beneficiary went from $5,500 to $11,900. The costs of our dysfunctional health-care system have already helped sink our auto industry, are draining state and federal coffers, and could ultimately imperil our ability to sustain universal coverage.

You may read the whole artice by clicking the link below:

Read more: http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande?printable=true#ixzz0a4Ii9xTu

In other words the status quo will lead us to a diseaster unless the market intervenes in some positive way. Think about it!

Staying Resilient During Tough Times

From time to time, we will include a blog posting from a Marino Center clinician on a topic of interest. The first issue is on the topic of resiliency in tough times authored by Deb Morrill MPH, RNCS, APN. Deb is a long time Marino Center clinician who focuses on women’s health.

As a seasoned health care provider, I have witnessed loss and crisis in many patients and most recently have experienced a tragic and sudden loss in my own family. Many individuals seem to show strength and resiliency during the most heartbreaking losses. A common armament of character, belief and coping strategies seem to be common among this group.
Resiliency is the ability or process by which people adapt successfully to life’s difficulties and challenges. It is the capacity to bounce back from a traumatic event or to thrive under seriously stressful situations

Three characteristics seem to be common among resilient people: a staunch acceptance of reality, a deep belief often buttressed by deeply held values, (that life is meaningful) and an uncanny ability to improvise.

This is often accompanied by a strong sense of community. The majority of individuals look to support from a formal or informal community. This is often a spiritual/faith community but may also be a bereavement group, AA meeting, work group, or chat room. I found myself reaching out to my co-workers and friends to organize a prayer wheel during my nephew’s catastrophic illness. I found much support and solace in the prayer, support, and community via email communication.

Spirituality and religious traditions may play a key role in providing solace and comfort. This outlet may offer shared belief systems, ritual and spiritual practices, community gatherings, support, care, and outreach. Communities seem to be a strong factor in resiliency. Altruistic behavior also may be beneficial for emotional health by releasing the hormone oxytocin which has sustained anti-stress effects. This means that providing service or doing good is actually good for you. You no longer need hesitate to ask a friend to pray or provide a favor, as the health effects will come back to that person. You can return the favor.

A regular meditation program can also strengthen resiliency. Herbert Benson’s studies show an association between relaxation response and positive neurochemical changes in the brain.
We will all need to test our resilience many times over in life.

Perhaps this is the time to reexamine our life beliefs, spirituality, and community involvement. It is not too late to develop a resilient self.


Special Note:
This article was written by Deb in memory of her nephew Eric J. Gaffney who died September 6, 2009 and his resilient, loving parents.

NIH GRANT AWARDED to MARINO CENTER

Studies in Patient-based Informatics for Comparative Effectiveness Research (SPICER)

The Marino Center, along with the University of Arizona, has been awarded a grant to study the comparative effectiveness of Integrative Medicine. The entire project award is just under 1 million dollars, with about half allocated to the Marino Center.

With the help of this grant money, we will examine the immense amount of clinical data, created daily at the Marino Center, to generate knowledge on the comparative effectiveness of treatment modalities. We will compare alternative and complementary therapies among themselves, and with conventional medicine. Traditionally medical research has relied on randomized controlled trials (RCTs) with specific focus. While RCTS's remain the gold standard for testing narrowly-focused questions, it has become increasingly clear that not all important questions about the delivery of health care can be answered by RCTs. Looking at real-world clinical encounters is a new way of conducting and thinking about research.

Ours is an observational study using event-stream analysis to provide patient-centered results. We will start by looking at four common conditions: back pain, fibromyalgia, irritable bowel syndrome, and peri-menopause. It is anticipated that further studies will also be done. While we intend to produce important disease-specific results from this project, we consider it a first step toward a much larger enterprise for changing how clinical research articulates with clinical practice. The long-range goal of this project is to create a sustainable model for collaboration of multiple clinical centers for conducting focused observational comparative effectiveness studies within and across multi-modality clinics, including more complex health care delivery systems and a very broad range of modalities.

Potential impact
1. Determine useful clinical treatments by providing patient-centered, evidence based medical information extracted from trajectories of care.

2. Improve research in IM by opening opportunities to mine clinical databases while maintaining scientific rigor.

3. Organize the collective experience and wisdom of medical practitioners in a way that spans medical systems, and bring the best treatment to each individual patient.

4. Create methodology that can develop neglected aspects of health and healing, such as patient choice and patient-practioner interactions.

Steering Committee:
Marino Center
Anne McCaffrey, MD, MPH
Robert DeNoble, MBA
Jennifer Cao, LicAc
Dan Himick

University of Arizona
Mikel Aickin, PhD
Ken Pelletier, MD

What’s Wrong/Right with the U.S. Health Care System

Recently, a young person applying to medical school asked me for assistance in getting information about our health care system so she could complete a section on the application that asked her to comment on what’s wrong with the health care system. Naturally, I was able to provide a lot of articles, papers, as well as my own analysis of the issues. After giving her the information necessary to do a decent job of responding to the question on her application, I began to think about how I would respond to such a question. I thought of two alternative responses; one that articulated the problems and deficiencies of the system and the other that concluded that there is really nothing fundamentally wrong with the system. Below is how I might have responded in each of these parallel universes, addressing the underpinnings of any health care system Access, Quality, and Cost.
　
The U.S. Health Care System is a Disaster and Needs Drastic Reform Now

Many recent books, articles, and presentations that I have read start with a variant of the statement "The U. S. Health Care System is a Disaster". Depending on the authors view point, the primary emphasis will be on one of the three underpinnings, Access, Quality, and Cost. Sometimes all three are woven together. The issues of access, or lack thereof, is usually made with the argument that 15% of the population at any one time is uninsured, and lack of insurance creates a barrier for people to seek and get health care services. For those lacking health insurance and become truly ill (as opposed to ailments that are relatively minor and self healing) the choice is often between suffering and/or dying or getting care and suffering the financial burden that in extreme cases can lead to bankruptcy and/or impoverishment . To place a significant portion of American citizens in this position is unconscionable.

Moving to quality, statistics that focus on medical errors leads the way. It is often said that errors occur from the overuse, underuse, and/or misuse of treatment interventions. Obviously, human error plays a part as well, even when there is no evidence of over-, under-, or mis- use of services. This is a topic for another day. It is tough to legislate quality, however incentives and/or penalties may be built into payment systems that reward or penalize a provider for behaving in a certain manner that is deemed to result in better outcomes or to reward or penalize on the basis of the outcomes themselves.

Cost is the really "boogey" man in the equation. The cost of providing health care to American Citizens puts a financial burden on employers, the government at all levels (federal, state, local), and on individuals and families. Cost may be controlled in two fundamental ways at the extremes, by (1) controlling supply and price at the payer level (i.e., restrict payments for services and reduce the price paid to providers for services) or (2) going to a totally consumer driven model where price is controlled by consumer choice and demand. Moving to either extreme would be a significant change and in many respects defines the two philosophical camps in the health care debate (government central control vs. a free market solution). However, unless costs are controlled, U.S. companies may be unable to compete in a global economy and governmental units will either have to curtail other services (education, defense, infrastructure) or raise taxes. Neither solution is very popular.
　
The U.S Health Care System is Fundamentally Sound and Does Not Need Significant Government Directed Reform

The health care industry is a significant driver of economic growth in the U.S. currently accounting for about 16% of the gross domestic product, and rising. The industry provides employment for numerous U.S. citizens from the highest level professionals to blue collar workers. Given the importance of health care to the U.S. economy any changes should consider the impact on the wider economic picture.

A key concern expressed about the current system is that it limits access to a portion of the population (the uninsured and underinsured). The percentage in this population segment is said to be about 15% or 45 million people. The reciprocal of these numbers are 85% and 255 million (the number of people who are insured). These numbers have remained relatively constant over the past several years. Obviously, the vast majority of Americans have good to very good access to health care services, at least from a financial standpoint. As for the minority who are un- or under insured, they have access to health care services, albeit limited, through government funded community health centers and hospital emergency rooms that are prohibited by law from turning people away. So maybe access is not such a big issue afterall.

The quality of care, as judged by the cutting edge innovation and treatment of serious diseases, in the U.S. is second to none. This innovation is fostered by the free enterprise system that provides big rewards for creative entrepreneurs. To take away the big reward incentives would severely reduce the advancement of medical care and hurt quality care going forward. So for the sake of continued advancement, do not inhibit the incentives to be creative.

So now we return to the "boogey" man, cost. The supporters or health care reform claim that if we do nothing, the rising health care costs will strangle government and make U.S. companies non-competitive in the global economy. Recent analyses of the Medicare spending have shown that there is a wide disparity in spending per capita for health care services in different parts of the country without much difference in mortality and morbidity outcomes. This begs for better standards of care that can lead to a more efficient system. The government, through the Medicare program, can take a leadership role, along with U.S. medical schools, to create "best practice" models. This will begin to push the cost curve for government expenditures downward over time. As for the private sector, the market will respond accordingly. Employers have already begun to shift the cost of health care to individuals employees through premium sharing, co-payments and deductibles. As this trend continues, we will move incrementally toward a consumer driven model. As more people with financial capability need to seek health care insurance on their own, the market will respond. Health insurers will develop products to meet the market need. It is likely the health insurance will move to a more catastrophic model, covering high cost interventions and procedures, while leaving individuals to pay for less expensive services out-of-pocket. When people need to pay directly for a service, they are more likely to become discriminating consumers. This will lead to people seeking better value for the dollars they spend, just like when purchasing automobiles or appliances.
　
What Direction Now??

Is the U.S. Health Care system so hopelessly broken that it needs significant government directed change or if we leave well enough alone, will the fundamentals of our free enterprise system take care of the problem?

In all likelihood, neither extreme position will prevail. We will see elements of both philosophical camps in a creative U.S. solution. Let’s hope that open minds and thoughtfulness on the part of our leaders prevails.

Americans Spend $34 Billion on Complementary and Alternative Medicine

Over the past few months, there has been a lot of talk about health care, or more accurately, health insurance reform. Obviously, any significant change coming from the Federal or State level will impact the Marino Center. It is my sense that our focus on primary care within an integrative delivery model will put us in a good position for the coming changes.

Within the currently proposed legislation, the value of primary care is being touted as a key to getting better health status outcomes through prevention and wellness leading to less dollars spent on “fixing” health problems that could have been prevented. Further, a recent a survey conducted by the CDC’s, National Center for Health Statistics reported that $34 billon dollars, or 1.5% of total medical costs were spent on Complementary and Alternative Medicine. The biggest single expenditure was for non-vitamin, non-mineral herbal supplements and other products (almost $15 billion) followed by practitioner visits ($12 billion), stretching and meditation-related classes such as yoga, tai chi, and qigong (($4 billion), homeopathic medicines ($2.9 billion) and relaxation techniques ($0.2 billion). Chronic pain, especially back pain, is by far the biggest reason that people turn to complementary and alternative treatments.

Other highlights from the report include:

- In 2007, 38 million adults made an estimated 354 million visits to CAM practitioners
- Two-thirds of the out-of-pocket spending were for treatments that did not involve a practitioner, such as over-the-counter herbal therapies and other therapies, classes and materials

Previously reported figures based on the same national survey showed that 38% of adults and 12% of children under the age of 18 used some type of alternative medicine in 2007.

Note: portions of he above was extracted from a WebMD Health News article

Senators Seek Coverage for Alternative Therapies

Last week, the Boston Globe reported that Senator Tom Harkin of Iowa is leading an effort to win insurance coverage for naturopathic doctors, herbal healers, mind-body specialists, and acupuncturists as part of health care reform. Backers of this amendment claim it could save tens of billions of dollars in the long run by providing less expensive and better alternatives to drugs and surgery in a variety of cases.

It is interesting to note that the amendment has bipartisan support as it is backed by Senator Mike Enzi, the ranking Republican on the Senate committee on Health, Education, Labor and Pensions. This committee agreed to pass the measure onto the Senate Finance Committee, which is working on companion legislation that may include crucial language regarding potential reimbursement.

Supporters of this amendment greet this action as a real breakthrough, regardless of the final outcome. It certainly confirms the model of care offered at the Marino Center.

In a general sense, the bigger picture here is that more attention is being paid to the front end of the health care system, i.e., prevention, wellness, and management of chronic conditions. This would be real health care reform if things move in this direction. Stay tuned.

Health Care Reform - Progress

Health care reform is front and center at both the Federal and State levels. The prominent theme at the Federal level is universal coverage, that is getting a major portion of the 45 or so million people who are not insured to get coverage, and somehow do this without breaking the Federal bank. In reality, this is not health care reform but health insurance reform. It seems the words "health insurance reform" are being used by President Obama. The belief is that the health care system itself can be transformed through health insurance reform. At the Massachusetts State level, the focus is on payment reform to control costs. For all intents and purposes, Massachusetts has achieved near universal coverage, with less than 3% of the population uninsured, the lowest in the nation.

Federal Reform Initiatives

Key elements in the proposed Federal reform bill (House Version) entitled: "America’s Affordable Health Choices Act" include:

• Requires individuals to obtain and maintain health insurance coverage. Those who do not obtain coverage will pay a penalty of 2.5% of modified adjusted gross income above a specified level. Subsidies would be provided to low wage earners through a sliding scale of affordability credits.
• Creates a Health Insurance Exchange to serve as a marketplace for individuals and small employers to comparison shop among private and public insurers. The bill proposes the creation of a public health insurance option that is supposed to operate on a level playing field with private plans included in the "Exchange" offerings. The public option is the most controversial aspect of the bill.
• Prescribes essential benefit design and administrative rules for health insurance products. Insurance companies will no longer be able to refuse to sell or renew policies due to an individual’s health status or to exclude coverage treatments for pre-existing conditions. The bill also prohibits lifetime and annual limits on benefits and limits the ability of insurance companies to charge higher rates due to health status, gender, or other factors. Premiums can vary only based on age, geography, and family size. Health insurance plans would have to submit an application to become a Qualified Health Benefits Plan (QHBP) in order to participate in the Health Insurance Exchange program.
• Promotes primary care, mental health services, and coordinated care within the Medicare program through a Patient Centered Medical Home Pilot Program. A patient centered medical home provides patients with direct and ongoing access to primary care by a physician or nurse practitioner who accepts responsibility for providing first contact, continuous and comprehensive care to such patients. The medical home serves a coordinating role for all of a patient’s care needs.

Administration of the health reform plan would fall under the authority of a new independent agency in the Executive Branch called the Health Choices Administration that will be headed by a commissioner appointed by the President. The Health Insurance Exchange would fall under the auspices of the Health Choices Administration.
There are many more provisions and aspects of the America’s Affordable Health Choices Act contained in its over 1,000 pages. Given the uncertain nature of the bills future and the certainty that it will be modified, it is not worth delving into the details at this point.
　
Massachusetts Reform Initiatives

Given the relative success of Massachusetts’s universal coverage initiative over the past several years, the issue at hand now is cost, which is stressing the state budget and the private sector employers and individuals who must purchase health insurance. To address the cost issue, the State in 2008, mandated the creation of a Special Commission on the Health Care Payment System to "investigate reforming and restructuring the system to provide incentives for the efficient and effective patient-centered care and to reduce the variation in the quality and cost of care". The recommendations of the Special Commission were published and made public on July 16th. The report identified the perverse incentives of the Fee for Service (FFS) payment system as the main culprit driving costs. As stated in the report, "FFS rewards overuse of services, does not encourage consideration of resource use, and thus cannot build in limitations on cost growth". The Special Commission recommends moving to a global payment system.

Key components of the Global Payment system are:

• Develop Accountable Care Organizations (ACOs) that accept responsibility for all or most of the care that enrollees need. ACOs will be composed of hospitals, physicians, and/or other clinician and non-clinician providers working as a team to manage both the provision and coordination of care for the full range of services that patients are expected to need.
• Foster patient-centered care and a strong focus on primary care. ACOs will receive global payments and in turn will disburse those payments among participating providers, using methodologies, including episode based payment and medical home models, of their choice.
  Use pay-for-performance (P4P) incentives to ensure appropriate access to care, and to encourage quality improvement, evidence based care, and coordination of care among providers and across sits of care.
• Share financial risk between ACOs and payers. Payers, including private insurers and self-insured employers, will retain their current role as holders of insurance risk for health insurances contracts and employee health plans. To ensure that ACOs are not subject to insurance risk, global payments will be risk adjusted for clinical and socioeconomic case mix and geography. Clinical case mix adjusters will reflect patient’s health conditions and differences in consumer incentives associated with benefit design. Socioeconomic adjustments will recognize other patient characteristics such as income status, to the extent that they have been demonstrated to influence health.
• Encourage widespread adoption of medical home models of care. The Special Commission recommends that steps be taken to ensure that the primary care practices in each ACO undergo the necessary practice redesign to become effective patient-centered medical homes ad that they are compensated in a manner that supports their operation.
  The Special Commission recommendations call for implementation of the global payment system over a five year period.
  　
  How Will the Proposed Federal and State Health Reform Initiatives Affect the Marino Center?

In both the Federal and State plans, greater emphasis is placed on the role of primary care in the overall health care system and the idea of "Patient Centered Medical Homes". The Marino Center has long emphasized the value of primary care and is well situated to develop into a medical home as conceived by the reform initiatives. At this point, the Marino Center will be most impacted by the State initiative rather than the Federal initiative.

A key question for us is what organization will undertake the role of the ACO that the Marino Center will be part of and how we will fit into the overall structure of the ACO. Based on our current limited information, the ACO will likely be at the Partners Community Healthcare, Inc. (PCHI) level. This is the organization that encompasses all of the Partners Healthcare hospitals (MGH, B&W, Newton Wellesley, North Shore. Faulkner), and all physicians who are part of the PCHI network. Since the ACO will be assuming "performance risk", it remains to be seen how cost controls and distribution of funds will take place. With the emphasis on primary care, the Marino Center should play a larger role in the overall health delivery system. Further, we will be called upon to deliver on P4P quality measures. We are well positioned in this regard given the advanced state of our electronic medical system.

Our current strategy is to continue our focus on providing quality care and increasing our capacity to deliver more primary care services by expanding the number primary care provider resources.

The Role of Electronic Communication in Providing Care

Our society is moving rapidly toward communicating electronically using email and social networking tools such as Twitter, FaceBook, MySpace, etc. It is inevitable that this form of communication will have a greater impact on the delivery of heath care, especially for Primary Care services, as more patients use electronic means to communicate with their health care providers.

In theory, the electronic communication was supposed to reduce the number of phone calls that a doctor receives from patients seeking medical advice or for follow-up after an in person visit. At first this sounded great as it was assumed that doctors could respond more quickly to emails than engage in lengthy phone consults. However, as with many great ideas, there are unintended consequences. While there is some evidence that the number of phone contacts between patients and physicians has decreased, the complexity of the email communications have increased to a point where some patients are seeing this communication as a substitute for a face to face visit with their doctor. Clearly minor problems can be addressed in a quick and safe manner with a very succinct response by a doctor. Other more complex situations are a different story.
Obviously, in these cases the correct response is to not provide a detailed response but to indicate that a face-to-face visit is in order.

There are a series of questions that get raised in this brave new world. Where is the line? How do you define medical standards? How do you educate patients regarding the appropriate use of electronic communication? How do you keep this communication secure and private? How does a doctor get paid for providing this service?

At this point, some clinical practices, like the Marino Center, have established a secure messaging system that allows, and some might say encourages, patients to communicate with their doctors through an electronic format. However three significant challenges arise; one is the increased volume of emails and the time necessary to respond, the second is the length and complexity of the communication requiring more time and thought to respond, and the third is the lack of compensation for this service. While patients may like the convenience it does place an added burden on the doctor. This was not supposed to be the case.

Possible solutions the electronic communication challenges are to:

Not permit electronic communication at all
Limit the length of the message (like Twitter)
Assign a triage nurse or administrative assistant to screen all electronic communication and respond directly to the simple questions and direct patients to make an emergent or urgent visit, if warranted.

Under any circumstance, adequate payment for these services by third party payers should be required. This would provide an incentive for practices to develop this form of care delivery, which will happen one way or another.

Health Care Reform – Really?

Last night, President Obama spoke to a group assembled at the White House on health reform that aired on ABC TV. At the beginning of the session, the host, Charlie Gibson, asked how many agree that we need to change the health care system in America. Everyone raised their hand indicating unanimous agreement. He didn’t ask the next logical question "How many of you think we will actually pass significant health reform that meets the President’s goals of universal coverage for all Americans, maintaining freedom of choice for people regarding selection of health care providers and treatment options, and reining in costs?"

Based on the backlash from those who are weary of a government run system and of the cost of a universal health plan, and those very powerful players who have a strong (although unstated openly) vested interested in the status quo, I am afraid that the answer would not be unanimous, in fact far from it. While all agree that we need to change, there is such a divergent view of how that change should occur. This is exactly the same place we were 16 years ago when the Clintons tried to change the system, and we see how that turned out.

So what is different now? As the President said, if we don’t change we will bankrupt the American economy. This may be on overstatement, but I think more people will suffer from lack of access to health care and will have to live with painful conditions and probably die sooner. Given that we have accepted a 15% uninsured rate for many years, it appears that we may be able to tolerate that for a longer period of time. What I am saying is that I am skeptical that we will see much change other than some form of insurance reform that opens up a market for individuals to purchase health insurance through a controlled market. This will accelerate the process of disconnecting health insurance from employers, which can be a good thing.

With respect to the cost issue, I still don’t have an answer, and I don’t think the President does either. The only thing I can figure is that new insurance policies will have high deductibles and co-payments that will deter people from accessing care, thus reducing demand. Reduced demand should reduce volume of care which will reduce costs. There are some strong arguments that we as a population are over treated and that less care may be a good thing. What do you think?

Health Care Reform – YOYO Health Care

Last month I wrote about health care reform and how two of the three parts of President Obama’s goals were easy to accomplish ( choice of health care plans and medical providers and access by all Americans to affordable health insurance coverage) but the third is near impossible under current conditions (rein in costs). In my May 15th blog, I talked about the Yin and Yang of Health Care, whereby the health care system, which is somewhat dysfunctional, is merely a by-product of the health care industry, which is focused on growth and profitability. Those very powerful industry forces along with the fear of a government take over and added federal costs, will, I believe, preclude any major health reform this year. I hope I am wrong, but I am skeptical that we will see much in the way of major reform. That’s not to say that there won’t be some incremental change, such as added regulation of insurance companies that require them to create an affordable individual, as opposed to group, insurance product. I suspect that these plans will resemble a catastrophic insurance model that will come with high deductibles and co-insurance payment. This will further move the U.S. away from an employer based insurance system (currently only 65% of all employers provide health insurance) to an individual market. This may not be all that bad depending on how helpful the health plans are in dealing with individual customers, rather than groups.

All of the possible changes that may occur will move us toward what I call YOYO Health Care: Your-On-Your-Own. We must all get used to making choices on our own regarding health insurance plans, medical providers, and treatment options. Already there is a move by major health systems and insurers to create a "Shared or Informed Decision Making" environment. In Boston, Partners Health Care is promoting the idea of sending patients with certain conditions educational DVDs. Conditions include, Coronary Artery Disease, HIP Osteoarthritis, Spinal Stenosis, Prostate Cancer, Herniated Discs, etc.

YOYO Health Care may work on the cost part of President Obama’s trilogy if there are real incentive built into health reform for self care, prevention, and wellness. In reality, the only thing that is going to slow health care spending is for consumers to avoid acute illness and to better manage chronic illness. Under the current system where the health care industry is rewarded for doing more, more care will be provided. In fact, the health care industry would like nothing more than to "sell" more of its products and services. This helps achieve their revenue growth and profitability goals.

Why Do Placebos Work?

Several blog posts ago, I addressed the value and impact of the therapeutic relationship (VITR). Since writing that post, I read several supporting pieces on the topic. One is from a fascinating book, Hippocrates’ Shadow - Secrets from the House of Medicine – What Doctors Don’t Know, Don’t Tell You and How Truth Can Repair the Patient Doctor Breach by David H. Newman, M.D. and the other is from Newsweek column by Sharon Begley entitled: "Hooked on a Feeling – This is your brain on a placebo".

Both sources refer to credible research to support the idea that placebos, referred to as sugar pills, a sham treatment, or an inert compound, cure illness and engender health and well-being.

So how can sugar pills, sham treatments, and inert compounds do this? The answer is the there is something to the "tending ritual". The best answer is from Dr. Newman’s book:

"Studies indicate that the significance of the tending ritual of patient – doctor contact is real, and so is the response. The actions and interactions of the patient and doctor when acupuncture is performed, the shared experience of tending and communication, was more powerful than that of almost any pill science has produced. While hard science, the active ingredient, should be respected and given the credit it is due, we must also acknowledge and understand the simplest, and in some cases the most powerful, medicine of all: the contact between doctor and patient."

Sharon Begley’s column states "if neuroscientists have learned anything about placebos, it is that …high-level mental functions control the nitty-gritty of lower-level brain processes. In other words the brain responds to expectations when provided by a trusted care giver.

A basic tenant of integrative medicine, as practiced at the Marino Center, is to foster that trusting relationship and use the art of medicine as Hippocrates envisioned.

The Definition of Integrative Medicine

Integrative medicine or integrative health is a relatively new term and used in various ways by various people. Some use the term in a very limited way to describe a new and different approach to a clinical condition that in fact has nothing to do with integrating anything. Others use the term to mean complementary and alternative (CAM) services, and nothing more.

At the Marino Center, we believe that integrative medicine has a much deeper and comprehensive meaning that is in concert with the definitions promulgated by the Bravewell Collaborative, The Consortium of Academic Health Centers for Integrative Medicine, and the National Institutes of Health – National Center for Complementary and Alternative Medicine (NCCAM). These definitions are presented below:

Bravewell Collaborative:

Integrative Medicine has the following characteristics:

1. Patient-centered care and focuses on healing the whole peson – mind, body, and spirit in the context of community;
2. Educates and empowers people to be active participants in their own care, and to take responsibility for their health and wellness;
3. Integrates the best of Western scientific medicine with a broader understanding of nature of illness, healing, and wellness;
4. Makes use of all appropriate therapeutic approaches and evidence-based global medical modalities to achieve optimal health and healing;
5. Encourages partnerships between the provider and patient, supports the individualization of care; and
6. Creates a culture of wellness.

The Consortium of Academic Health Centers for Integrative Medicine:

"Integrative medicine is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, health care professionals and disciplines to achieve optimal health and healing."

National Institutes of Health – National Center of Complementary and Alternative Medicine:

"Integrative medicine combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness."

Regardless of how integrative medicine is defined and delivered, the true test of its value is how it effects the health status of patients (quality) and the impact on the consumption of health care resources (cost). If it improves the health and well being of patients and uses resources economically, it’s a winner! The Marino Center is committed to finding out the answer to the quality and cost questions and to be a leader in the health care reform movement.

Health Care Reform and the Yin and Yang of Health Care

A health care reform plan is being crafted in Washington that would require all Americans to carry health insurance and would help families making less than $88,000 pay the premiums. Employers would also have to pay into the system. President Barack Obama said the final legislation must:

Rein in costs
Guarantee choice of health plans and medical providers
Ensure that all Americans have access to affordable coverage

Accomplishing the choice and access to affordable coverage is relatively easy compared to reining in costs. Legislating provisions of public and private health plans to guarantee choice and eliminating discriminatory practice that exclude certain individuals, and providing government subsidies are all very doable . But the cost part is much trickier and here is where the Yin and Yang of health care takes over.

The focus on health care reform is on the health care system. However, the power force behind the health care system is the health care industry. The system and the industry represent the yin and yang of health care. The health care industry consists or the many organizations that provide health care related products and services. Each of these organizations, under the free enterprise system that we so cherish in America, work very hard to grow revenues and profits. As these organizations achieve their revenue growth targets, their collective success adds to the cost of the health care system. To put in succinctly, every dollar of cost to the health care system is a dollar of revenue to the health care industry. In essence, the health care industry collectively will do everything in its power to preserve and defend its revenue flow. The key question to ask when one hears that costs will be reduced is who will see a reduction in revenue?

There is a lot of vested interest by the collective players that comprise the health care industry in the unregulated status quo. Its going to take a lot of clout to move this very powerful and entrenched force. We will see in the coming months how this issue will be dealt with.

Integrative Medicine: A Vital Part of The New Health Care System

There is a lot of momentum for major reform of our health care system at the federal and state levels. Cost, quality, and access issues have reached a tipping point and the convergence of political, economic, social forces have virtually assured that health care reform will happen now.

The Marino Center and its integrative care delivery model have been ahead of its time with a focus on prevention, wellness, and treating the whole person. Some aspects of the coming reform will move the whole system toward the Marino model.

On February 26th, Senator Kennedy convened a hearing on integrative medicine. This hearing was held at the same time as the Institute of Medicine’s Summit on Integrative Medicine. Those testifying before Senator Kennedy’s committee included Andrew Weil, M.D., Mehmet Oz, M.D., Mark Hyman, M.D., and Dean Ornish, M.D.

The statement offered by Senator Kennedy provides a succinct summary of how and why Integrative Medicine is a vital part of the future of health care in America. His statement is presented below in its entirety:

Statement of Senator Kennedy, February 26, 2009:

"The American health care system urgently needs repair and reform. Today as a nation, we spend 16% of our gross domestic product on health care, more than any other country in the world. Yet health outcomes of Americans are ranked 37th in the world by the World Health Organization. Our system is often called a "sick care" system, not a health care system, because it is designed to treat diseases and illnesses, instead of promoting good health and wellness over the lifespans of our people.

Genuine health reform therefore requires a major transformation in our national mindset on how we care for ourselves and others. It must incorporate and encourage disease prevention activities and lifestyle changes that promote long-term health and well-being. The current incentives in our health care system that lead to over-treatment and mistreatment must be changed to promote high-quality, appropriate, and coordinated health care. The nation’s alarmingly high and growing rates of obesity and chronic disease today are a clear call to action. By preventing diseases before they start and adopting a broader approach to medicine, we will actually reduce costs in the long run, and we will extend and improve the quality of life as we do it.

To achieve this fundamental shift in our nation’s health care mindset, it will be necessary to reform how medicine is practiced. Low-cost or even free health screenings and vaccinations will encourage individuals to take part in preventive medicine. Patient-centered and coordinated care that addresses the whole person – from genetic predispositions, to life-style choices to potentially harmful conditions – is essential for treating acute diseases and managing chronic conditions.

We must also adopt a more integrated approach to medicine, through health care that addresses the mental, emotional, and physical aspects of the healing process in order to improve the depth, breadth, and patient choice in clinical practice.
Further, we must incorporate prevention, wellness, and more patient-centered approaches as fundamental components of medical education and the training of health providers. In order to reach the patient effectively, integrative practices must be accepted throughout our health care system, and especially in the education of health care providers and the consumers who will benefit.

Finally, we can look beyond the traditional health care system to the community itself – to local environments, where we can build sidewalks and bike lanes; to workplaces, where wellness programs can help employees include healthy nutrition and exercise in their lives; and to schools, where we can provide preventive screenings and lay a strong foundation for students to lead healthy lifestyles from and early age.

Americans deserve a health care system that provides this kind of high-quality, patient-centered care, and encourages individuals’ choices and control over their health. The result, as I have said, of this new focus on prevention and health promotion will be lower health care costs and longer, healthier lives.

I commend Senators Harkin and Mikulski for their continuing leadership and this important issue, and I look forward to working closely with my colleagues on the HELP and Finance Committees and with President Obama to achieve or fundamental goal of improving the quality of health care, expanding access to such care for all our people, and reducing the financial burden of such care."

The Value of the Therapeutic Relationship Between Patient and Health Care Professional

What is the nature of the relationship that a patient has with a health care provider and does it play a role the health and wellness of individual patients?

The answer depends on the nature of the patients’ visit and the focus or specialty of the health care professional. For psychotherapists, the therapeutic relationship is the core clinical tool and very little progress will be made if it doesn’t exist. On the other end of the spectrum are technical specialist such as anesthesiologists, pathologist, and radiologists who work behind the scenes and have very little interaction with patients. However, for these specialists, a patient assumes the level of the practitioner’s competence has been reviewed and approved through licensing and credentialing processes by hospitals or state boards. In other words, these specialists have been sanctioned by authoritative sources carryout their fiduciary responsibilities.

In between the two extremes, are primary care providers and a wide variety of medical and surgical specialists. The major difference along this continuum is the on-going relationship with PCPs and some medical specialists (e.g., cardiologists) verses the episodic relationship with most surgical specialists and some medical specialists (e.g., dermatologists). I believe that that greater frequency of contact that a patient has with a provider, as well as the comfort of knowing who to call when urgent needs arise, drives the value and impact of the therapeutic relationship (VITR). A high degree of VITR will likely motivate patients to comply with health and wellness regimes (e.g., diet and exercise routines) as well as treatment protocols. In general, this emphasizes the role of PCPs where the frequency of patient/provider contact is highest.

At the Marino Center, there is a strong belief in VITR. To this end, patients are provided with a generous amount of time with their providers. While time is not the only element that builds VITR, it’s a good start.

Pillars of Integrative Healthcare

The Marino Center defines integrative healthcare as not only the combination of conventional medicine with complementary and alternative medicine (CAM) in one clinical setting, but as care focused on health and healing with an emphasis placed on the patient-provider relationship.

The key components of the Marino integrative healthcare model are presented below. Supplementary to these core services are various group programs focused on improving and maintaining a state of well being. Such programs include stress reduction, weight loss, and yoga.

While any one of the services listed below can be helpful for the conditions noted, the true value of an integrative care approach is that the practitioners in each of these disciplines collaborate with each other to move the Marino Center patients to their optimal health status.

Acupuncture
Acupuncture is used to relieve pain and heal a variety of conditions, including arthritis, asthma, PMS, stress, digestive problems, muscular injuries, and more.

Chiropractic
Special attention is given to spinal biomechanics as well as musculoskeletal, neurologic and nutritional relationships.

Craniosacral therapy
Therapists work with the spine and skull to treat mental stress, neck and back pain, migraines, TMJ Syndrome, and for chronic pain conditions such as fibromyalgia.

Environmental medicine
A comprehensive approach to evaluating, managing and preventing the adverse consequences of environmentally triggered illnesses, including allergy testing and treatment.

Massage Therapy
Massage Therapy can be used to treat a variety of medical conditions, including sports injuries, asthma, PMS, lower back pain, arthritis, Carpal Tunnel Syndrome and stress.

Mental Health
Individual, group and couples psychotherapy to help you identify and change the way you respond to life’s stresses.

Nutrition counseling
Examines the critical role of food in health maintenance and disease prevention. Helpful for a wide variety of conditions, including obesity, diabetes, pregnancy/fertility and allergies.

Pain Management
A variety of treatments for pain, including acupuncture, massage, energy healing and chiropractic.

Physical Therapy
Physical therapists provide services to patients who have impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes.

Primary care
Primary care with a significant difference: Extended visits, strong personal relationships with an emphasis on screening and prevention, and discussion of diet, exercise, stress and lifestyle.

The Myth of Early Detection – Evidence Based Medicine?

One of the key questions raised about treatments that differ from mainstream medicine is "what is the evidence that it is safe and effective?" A very valid question indeed. Clearly it is imperative that we learn what works and what doesn’t. But, it is not quite that simple. Some approaches work for some people and not for others and it is the experience and skill of the clinician to make the right match between a patient’s condition and the best clinical approach. In other words, the clinician must practice the art of medicine.

In recent days, several studies have been released that bring back into the spotlight the questionable validity of the assumption that early detection of a disease and the screening required to make this detection is the gold standard of quality medical practice. The two screenings for early detection that are most common are PSA for prostate cancer and mammography for breast cancer. Indeed medical practices are measured and rewarded based on achieving high percentages of their patient populations getting such tests. The higher the percentage screened the more "pay for performance" dollars flow to the practice. The economic incentives trump clinical value. The authors of these studies argue that the public is not currently presented with a balanced view of the screening, with potential benefits overemphasized and potential harms rarely discussed.

The conclusions of these studies have shaken conventional medical thinking. It makes me think of the old adage "half of what is learned in medical school is wrong, the only problem is figuring out which half".

Unfortunately, the recent studies do not provide much guidance to patients and their physicians other than to provide a balanced view. I suspect that most patients are not going to say "thanks for information doc, I will do more research and analyze what I find and get back to you with my decision". They are more likely to say "so what do you recommend that I do?" The response in all likelihood, despite conflicting evidence, is that the patient should go ahead with the screening. Why, because of fear of a malpractice charge for missing a cancer diagnosis and the economic incentives mentioned above.

The bigger issue than these specific study findings is what else do we take as absolute truth in medicine that is wrong? In discussing this issue with John Bordiuk, one of the Marino Center doctors, he said the only "absolute" truths in preventing illness and maintaining wellness is eat a proper diet, get a decent amount of exercise, get adequate sleep, and control stress levels. This is more powerful in protecting health than any screening tests we know. Not very high tech but it works a majority of the time for most people.

Is There Any Money in Integrative Medicine?

This is the title of an article in the March issue of HealthLeaders magazine. In essence, the article focuses on the continued development of integrative medicine centers based at academic medical centers. Specific institutions that are mentioned are Johns Hopkins Integrative Medicine and Digestive Center in Baltimore, Allina Hospitals and Clinics program at Abbot Northwestern Hospital in Minneapolis, and Duke University Medical Center, in North Carolina.

Most of the article features commentary by Linda Lee, MD, director of the Johns Hopkins Integrative Medicine program. Dr. Lee comments about the misconceptions with the terms "alternative" and "complementary", suggesting that to some, alternative connotes rejection of Western medicine and complementary means complimentary, which means free, which the service is not. According to Dr. Lee, Integrative Medicine means enhancing Western medicine, not rejection of one over the other. I wholeheartedly agree that we should refrain from using the terms alternative and complementary, especially alternative.

So what about the ability of having Integrative Medicine programs to be financially viable? Dr. Lee suggests that such programs do have the potential to generate financial returns, but it takes time. Paul Keckley, executive director of the Deloitte Center for Health Solutions offers that integrative health centers may not be profitable now, but that could be changing. He says that evidence of the efficacy of integrative health programs is growing and winning over some traditional medicine skeptics.

Our experience at the Marino Center is that to be financially viable, an integrative health center must be primary care centric and truly integrative. Unless holistically minded primary care is at the center of the clinical model, it is highly unlikely that a program that contains only non-primary care services, such as acupuncture, chiropractic, physical therapy, therapeutic massage, etc. will have financial staying power. In short, the primary care centric model is what has enabled the Marino Center to grow and develop as a self-sustaining integrative health entity.

While I agree with much of what Dr. Lee and Mr. Keckley say about the clinical and human value of the integrative health approach, financial viability is critical to sustain this model of care.

"Fragmative" Healthcare – A Personal Experience

I suspect that the opposite of Integrative health is "Fragmative" health for lack of a better term. I experienced this first hand when my family was confronted with what turned out to be harrowing end of life experience in a hospital in New Jersey. In brief, my 87 year old mother-in-law was taken to the emergency room of her local hospital suffering from a severe rash and swelling on her face and tongue which made it hard for her to breathe. The working diagnosis by the ER doctor was shingles, a painful viral infection. It appears that my mother-in-law’s immune system was so compromised that her presenting condition led to a positive test for viral encephalitis. She was treated intravenously with a strong anti-viral drug that affected her kidneys. This led to us having to make a decision regarding whether to have her put on dialysis while she underwent a 4 to 6 week in-hospital treatment with the anti-viral. At his point she was no longer conscious and was unable to speak for herself. Fortunately, she had an advance directive and living will which stipulated that she did not want medical interventions if her chances for survival with a reasonable quality of life were very low, which we felt they were. We followed her directives and had all therapeutic treatment stopped and moved to comfort care only. She was transferred to a hospice unit within the hospital where she died about 6 hours later.

I am sure this experience is quite common and many families have or will face similar situations. However, in reflection, the fragmentation of care was palpable. For the most part, the "system" of care in the hospital functioned as planned. During the course of 6 days, 7 or 8 different doctors provided diagnosis and treatment and an equal number of nurses and nursing assistants contributed to her care. All of these caregivers were complete strangers. Her long-time primary care physician and cardiologist were no where to be seen. This is not because they didn’t care about her, but rather this is the new paradigm of care when one is hospitalized.

So the key question for us was "Who is coordinating the various players on the team?" After asking this question in an assertive manner, the nursing director of the inpatient unit stepped up to assist. From a medical point of view, we were told that the coordinator was the "hospitalist" on duty at that moment. A hospitalist is a doctor or group of doctors hired by the hospital to care for inpatients. In the past, your own primary care physician would visit you in the hospital and direct your treatment. Now your primary care physician stays in his or her office and very rarely comes to the hospital. Under ideal conditions, the hospitalist sends information about your in-hospital treatment to your PCP, however, there is very little contact during the course of your in-hospital stay. Many times, your PCP doesn’t even know that you are in the hospital.
Since the "hospitalists" work as part of a group, the "on-duty" physician changes daily by shift. It is not even worth trying to remember their names. In the end, the relationship is with a "System" that consists of many players, each compassionate in their own right. In truth, the coordination of care falls to one or several members of one’s family. The experience of dealing with multiple clinicians, each with their own specialty, and not really talking to each other is the epitome of our "fragmative" care system.

It may be that in the highly intensive inpatient level of care, "fragmative" care is unavoidable. However, one should never have to experience this fragmentation when being cared for outside the hospital setting. Based on this experience, I gained a greater appreciation for Integrative care.

Report from Washington - IOM Integrative Medicine Summit

Three Marino Center staff members, Bob DeNoble, Anne McCaffrey and Andi Brown were fortunate to attend the recent Summit on Integrative Medicine and the Health of the Public sponsored by the Institute of Medicine of the National Academies. This was an outstanding opportunity to learn about trends in health care and to receive validation that, at the Marino Center, we are at the leading edge of a movement to change health care delivery in this country.

Dr. Ralph Snyderman, Chancellor Emeritus of Duke University and James B. Duke Professor of Medicine at the Duke University School of Medicine, offered a diagnosis of what’s wrong with health care today: Health care is a $2.4 trillion industry, that is fragmented, disease-oriented and reactive, with a find-it and fix-it approach. The prescription: bring back the centrality of the individual, and integrative approaches, systems, and resources. He outlined the five dimensions of integrative medicine: 1) it addresses a person’s physical, emotional and spiritual aspects; 2) it extends across the whole spectrum of care, including prevention, treatment and rehabilitation, and end-of-life care; 3) care is coordinated across the range of caregivers and institutions; 4) care is integrated around and within the individual patient, and 5) there is openness to multiple modalities of care.

Above all, we need to think not just about preventing diseases but instead of enhancing health and well-being. Health promotion should be where all health care starts. In the future, there will be a new model for more personalized care, with patients owning the tools of empowerment, and the physician acting as a mentor.

Bill Novelli, CEO of AARP, remarked that 44% of all deaths in the United States can be prevented by behavioral change. What’s needed is a national public policy initiative aimed at health promotion. Right now, we know what to do, but not how to get people to do it. As George Halvorson, Chairman and CEO of Kaiser Foundation Health Plan put it: "Make the right thing easy to do. Let’s start by giving patients a printout of their plan for being healthy. Electronic medical records – which the Marino Center has had since 2002– are a vital tool. In the perfect system, we’ll be able to access all the data about all the people all the time."

A theme of the conference was the misplaced priorities of a reimbursement system that rewards expensive procedures, many of which would be unnecessary if patients engaged in more health-promoting behavior, which would cost insurers, businesses and individuals MUCH less money. A national awareness campaign would be a good place to start.

Dr. Donald Berwick, President and CEO of the Institute for Healthcare Improvement defined health as "the extent to which the body can heal itself; then medicine becomes the servant." He presented Eight Rules for Health Care: 1) Place the patient at the center; 2) Thoroughly customize; 3) Welcome family, loved ones and community; 4) Maximize healing influences within care; 5) Maximize healing influences outside of care; 6) Rely on sophisticated, disciplined evidence; 7) Use all relevant capacities and waste nothing; and 8) Connect helping influences with one another.

An outstanding presentation by Dr. Dean Ornish, Founder and President of the Preventive Medicine Research Institute, offered the astounding fact that we can change our genes by changing our lifestyles, through, for example, meditation. He also noted that the more stress we have, the lower our brain waves, which can lead to depression. Highlighting another often-repeated theme of the conference, he noted that lifestyle changes can be superior to drugs in making us healthier.


Bob DeNoble, the Marino Center’s President and CEO was invited to participate in a Priority Assessment Group focused on DESIGNING AND BUILDING ECONOMIC INCENTIVES FOR INTEGRATIVE MEDICINE. The group was asked to address four questions (1) What are the three most important priorities in addressing the focus issue?, (2) Who are the key actors for implementation and their roles?, (3) What might be achievable 3 -year and 10 - year goals?, (4) What are the next steps? Bob offered the following for the group to discuss:

What are the three most important priorities?:

• Shift focus and resources from therapeutic interventions to wellness and prevention
• Demonstrate how Integrative Medicine is a disruptive innovation in the overall health care system leading to lower costs and improved quality
• Provide evidence that primary care centric integrative medicine produces superior patient outcomes as measured by patient’s health status, less use of high cost/high tech diagnostic and therapeutic interventions, and drugs
  
  
  Key Actors:
• Individual Consumers: Take active role in self care and maintaining wellness
• Research Institutes: Lead evidence based outcomes research on integrative medicine models
• EmployersTake an active role in the health and wellbeing of employees by providing economic incentives to practice prevention and achieve wellness
• Third Party Payers: Alter perverse incentives that encourage high levels of high cost services and shift resources to wellness and prevention
• Federal and State Government: Assume same role as employers for people covered by Medicare and Medicaid
  

What might be achievable 3 -year and 10 - year goals?

3 year goals:

• Ensure that integrative medicine plays a role in the inevitable health care systems reform
• Garner resources to conduct meaningful outcomes research
• Bring integrative medicine to the workplace
• Expand primary care resources by creating a new level of primary care provider

10 year goals:

• Transform the model of healthcare delivery to focus on primary, secondary, and tertiary prevention, thus improving the health status of the U.S. population and reducing health care expenditures to account for less than 15% of the GDP
  

What are the next steps?

• Create a collaboration between research entities and front line integrative clinical care providers to evaluate the effectiveness and efficiency of the integrative care model. Both components of this collaboration are required to provide sufficient expertise and data to accomplish this task.

One last bit of learning; the Marino Center model, in which primary care and complementary modalities are housed synergistically together under one roof, is rare if not totally unique. Attendees were very interested in knowing more about how our model works, and how they might replicate us.

Report From the Summit on Integrative Medicine

The first day of the Summit at the Institute of Medicine was action packed with an all star lineup of thought leaders in the field of medicine. Harvey Fineberg, President of the IOM provided opening remarks followed by Ralph Snyderman, Chancellor Emeritus of Duke University and chair of the Summit Planning Committee. Dr. Snyderman provided the following framework comparing conventional care and integrative care:

Conventional Care:

• Reactive
• Sporadic
• Disease Oriented
• Find It/Fix It
• Physician Directed
• Dogmatic

Integrative Care:

• Proactive Life Care
• Continuity of Care
• Health/Prevention
• Individual Empowerment
• Enlightened

An interesting discussion involved whether to call this form of care Integrative Medicine or Integrative Health. There seemed to be more support for Integrative Health by the more than 600 attendees. More to come on the Summit in the days ahead.

Electronic Health Records and Integrative Health

We are hearing that one of the ways to “save” our healthcare system is to have a massive move toward electronic health records (EHR), sometimes referred to as electronic medical records (EMR). The consistent use of up-to-date information by health care providers is supposed to enable providers avoid medical errors (which are costly) and improve the overall quality of care. The theory is that high quality care is cost effective care. Obviously, just because a provider has access to a more complete and comprehensive EHR does not automatically mean that your care will improve. Health care providers have got to review the record and consider its contents in the context of a patient’s presenting problem. Most providers these days barely have time to review their own record let alone a collection of diverse practitioners who may have provided services to a patient in a variety of settings.

An EHR in an integrative health setting is an essential part of providing truly integrative care. In a typical integrative health center, practitioners will take the time to review a patient’s record and use its contents to influence clinical interventions. At the Marino Center, we use an advanced version of the GE Centricity system that is used by ALL practitioners, including primary care physicians and nurse practitioners, specialist MDs, acupuncturists, chiropractors, physical therapists, massage therapists, nutritionists, allergy and IV nurses, and mental health providers. This comprehensive record is essential to supporting the integrative health model. In this manner, integrative health can be a leading example of the value of a “patient centric” health record.

Summit on Integrative Medicine and the Health of the Public

Later this month, several of my Marino Center colleagues and I will attend the Institute of Medicine Summit On Integrative Medicine and the Health of the Public in Washing ton DC. This conference has reached capacity enrollment of over 600 with a waiting list of several hundred more. Several papers have been commissioned for this conference and may be accessed at
http://www.iom.edu/CMS/28312/52555/62252/62351/62353.aspx. These papers provide a comprehensive overview and analysis of Integrative Medicine.

A key issue raised in several of these papers is the need for a standardized definition of integrative medicine. An appropriate baseline is form the Consortium of Academic Health Centers for Integrative Medicine which states “Integrative Medicine is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals, and disciplines to achieve optimal health and healing”.

I will report back on the Summit’s proceedings in early March.

Perceived Benefits of Complementary and Alternative Medicine

Dr. Anne McCaffrey, the Director of Research and Education at the Marino Center for Integrative Health, was part of a research team that conducted a study of the perceived benefits of Complementary and Alternative Medicine. The purpose of the study was to examine the benefits associated with CAM treatments from the patient’s perspective using a whole systems research approach as a guiding framework. The study involved focus groups of six to eight patients each, all of whom have experienced CAM therapies. The results of the study will be published in Open Complementary and Alternative Medicine Journal.

In general, participants described physical health benefits including relief and improved function, and positive psychological benefits such as improved coping and resilience. Social health benefits that arose from the positive aspects of the patient-practitioner relationship were also reported, including support and advocacy. In addition, participants identified empowerment, increased hope and spiritual growth as results of receiving CAM treatments.

The End of Primary Care As We Know It - Part IV - A New Paradigm

Is There A Way to Match Patient Needs with Provider Competence, Reduce Costs, Increase Compensation for Primary Care Physicians, and Expand Availability of Primary Care Resources?

For most primary care visits, it may be argued that the primary care physician is over- qualified. And since the payment system is geared to the services provided, not the level of skill or competency of the provider or the amount of time spent with a patient, it follows that the over-qualified primary care provider is compensated at a level well below his/her capability. The low level of compensation is a significant factor in the increasingly common decision of young doctors to not choose primary care as a profession, contributing to the primary care physician shortage.

This patient need/provider competency imbalance begs the question: How can we correct this imbalance expand the availability of primary care resources, reduce costs, and capitalize on the full extent of primary care physician’s expertise. These multifaceted, but interrelated goals require a new, somewhat radical health delivery paradigm.

A New Paradigm for Providing Primary Care

The proposed paradigm shift is built around the idea of "letting the solution fit the problem". As stated previously, for a significant number of primary care patient visits, the expertise of primary care physicians is more than required and the payment for these services is commensurate with the low complexity of the "problem". The key question is whether it is possible to train professionals to be Primary Care Providers (not Primary Care Physicians) who can properly manage many of the minor problems as well as preventative services now provided by primary care physicians? In some respects, the answer is evident, we already do. Both nurse practitioners and physician assistants fill this role in some practice settings.

The Primary Care Provider - A New Health Care Professional

The time and expense for someone to become a fully qualified and licensed nurse practitioner or physician assistant is substantially less than the time and cost for someone to become a medical doctor. Accordingly, NPs and PAs earn less than MDs, however the ratio of the training cost to annual compensation is substantially lower. The chart shows approximate comparisons. These calculations do not take into account the MD’s low compensation during a three year required residency, which would make the differential more pronounced.

Primary Care Medical Doctor

• Average Cost for Education $200,000 - $300,000
• Average Annual Compensation $140,000 - $150,000
• Ratio of Cost to Compensation 1.3 – 2.1

Nurse Practitioner/Assistant Physician

• Average Cost for Education $40,000 - $50,000
• Average Annual Compensation $75,000 - $100,000
• Ratio of Cost to Compensation 0.44 – 0.67
  
  
  The cost to compensation ratios for NPs and PAs are more in balance and, could encourage people to pursue this career.
  
  If NPs and PAs are to some degree already filling the role of "physician extenders" why do we need to create a new category of provider, the PCP (Primary Care Provider)? The answer is that the role of the new PCP is not that of physician extender, but rather a recognized independent health care provider on the health care delivery continuum who is licensed to practice primary care and is credentialed as such by third party payers. The title of "nurse" or "assistant" should not be used for the new PCP as those titles have historically indicated a lower level in the health care hierarchy. The PCPs should be considered and treated like mainline health care providers.
  
  Education and Training of the New Primary Care Provider
  
  A possible model for Primary Care Provider education and training may be a two year academic program with a one year internship. The academic program for PCPs could be a blend of the first two years of medical school, nurse practitioner, and physician assistant programs. A major emphasis would be on providing routine care with a very strong component of the training focused on when to refer a patient to a medical doctor for diagnosis and care. A clear set of protocols would need to be developed regarding when to refer patients to more experienced and deeply trained medical professionals.
  
  Future Role of the Internal Medicine and Family Practice M.D.
  
  Internal medicine and family practice physicians would become specialists who, like other specialists, would see patients referred to them, mostly from PCPs, who are in need of higher level diagnostic attention or medical treatment,. Under this system, the internal medicine and family practice trained physicians will be called upon to deal with patient related issues and problems that require their level of skill and training. In this manner there would be a more productive matching of patient need/provider competency.
  
  How Will This New Paradigm Evolve?
  
  At the present time, the Primary Care Provider as envisioned in the new paradigm does not exist and will take several years to create. However, the role of a Nurse Practitioner is very much evolving in this direction.
  
  Nurse Practitioners have been authorized to work fairly independently in mini-clinics housed in chain stores such as CVS. Further, recently passed health reform legislation in Massachusetts (Chapter 305 of the Acts of 2008) requires health insurance plans to recognize nurse practitioners as participating providers on a nondiscriminatory basis, for health maintenance, diagnosis and treatment. The legislation goes further, stating that "such coverage shall include benefits for primary care, intermediate care, and inpatient care, including care provided in a hospital, clinic, professional office, home care setting, long-term care setting, mental health or substance abuse programs, or other settings when rendered by a nurse practitioner who is a participating provider and is practicing within the scope of the nurse practitioner’s license to the extent that such policy or contract currently provides benefits for identical services rendered by a provider of health care licensed by the State."
  
  An insurance carrier that requires the designation of a primary care provider shall provide its insured with an opportunity to select a participating provider nurse practitioner as a primary care provider or to change its primary care provider to a participating provider nurse practitioner at any time during their coverage period.
  
  It remains to be seen how this legislation will be implemented; however between the mini-clinic model and this legislation, the seeds have been sown to move in the direction of the new paradigm of primary care delivery.
  
  The pathway to create the new PCP may be through an enhanced nurse practitioner track or through a conversion of some medical school slots. Either way, a collaborative effort between medical societies, federal and state licensing and regulatory authorities, and third party payers is required.
  
  Conclusion
  
  The U.S. health care system is the most expensive in the world yet it is hardly the best. The Commonwealth Fund recently released its second national scorecard on health care showing that the U.S. spends more than twice as much per capita for health care as most other industrialized countries, but has fallen to last place among those countries in preventing deaths through use of timely and effective medical care. Perhaps the expansion of the primary care resource as envisioned above could provide one step in the right direction to increase access to care.

The End of Primary Care As We Know It - Part III

Are Fully Educated and Trained Medical Doctors Needed as Primary Care Providers?

All medical doctors go through the same four year medical school education, plus a minimum of three years of residency training. At the end of the seven years, the now educated and trained doctors have incurred similar costs and have earned roughly the same amount from their residency stipends. So, aside from those with independent means, upon graduation, all newly-minted doctors are in the same financial position, facing a staggering debt ranging from $150,000 to $500,000

From this point on, the economic and practice differences take shape. A fresh out of residency orthopedic surgeon will command compensation at least twice that of an experienced primary care physician. At the same time, the orthopedic surgeon will immediately be called upon to use his/her highly honed technical skills to treat orthopedic conditions, while the primary care physician may see a variety of patients, including healthy people coming for an annual physical exam, as well as others with minor, easily treated medical conditions. A small fraction may have a serious illness that requires significant medical intervention such as medication and or other non-invasive procedures.

The focused attention and time of the primary care physician is required no matter where on the complexity continuum the patient falls. However, insurance companies reimburse at a lower rate for less complex medical issues, based on the theory that such care does not require the full extent of the primary care physician’s skill, and is therefore worth less than if the patient presents with a high level of complexity.

Is there a way to match patient needs with provider competence, reduce costs, increase compensation for primary care physicians, and expand availability of primary care resources? The next blog post will address this question and propose a new paradigm for providing primary care.

The End of Primary Care As We Know It - Part II

What Do Primary Care Physicians Do and What is it Worth?

According to one of several definitions by the American Academy of Family Physicians, "Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the "undifferentiated" patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis".Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). Primary care is performed and managed by a personal physician often collaborating with other health professionals, and utilizing consultation or referral as appropriate.

For many years, comparative compensation surveys have shown the work of primary care physicians to be valued less than that of specialists. So why is primary care considered of lesser value than services by specialists? One possible reason is that specialists deal with "differentiated patients", i.e. those who have defined problems that require a high skill level to treat. Only sick people seek the services of specialists while a vast majority of patients seeking services from a primary care physician are not seriously ill or have only minor illnesses that can be readily diagnosed and treated. Third party payers do not pay a high fee for treating minor problems or no real medical problem at all. Advocates argue that the services of primary care physicians is undervalued stating that primary care physicians can resolve minor problems before they become major problems, and they may be able to influence patients to behave in a manner that promotes wellness. Obviously, neither of these arguments has influenced society to place a high economic value on primary care physicians’ services.

In fact nurse practitioners may be equally capable of providing a similar form of care. And regarding wellness promotion primary care physicians can only have limited influence on patients compared with other forces in the environment, especially given that relatively healthy patient may visit a primary care physician one or two times a year, and patients under thirty even less frequently.

This begs the question "Are Educated and Trained Medical Doctors Needed as Primary Care Providers?" This will be addressed in the next blog post.

The End of Primary Care As We Know It - Part I

The signs of a pending crisis in primary care, the true front line of our healthcare system, are all about us, and not much is being done to deal with this potentially explosive problem. In this and future blog posts, I will present a diagnosis of the problem and propose a potentially radical solution. The discussion will be built around the following questions:

• What do primary care physicians do and what is it worth?
• Are medical doctors needed as primary care providers?
• Is there a way to match patient needs with provider competence, reduce costs, increase compensation for primary care physicians, and expand availability of primary care resources?

The shortage of primary care physicians has been well known for some time and the situation continues to worsen. The most recent survey of fourth-year medical students published in the Journal of the American Association reported that only 2% plan to work in primary care. This is down from 9% in 1990.

Google" "Primary Care" and dozens of articles appear regarding "the problem". In a nutshell, the shortage problem is attributed to two factors: compensation disparity between primary care physicians and specialty physicians; and lack of job satisfaction among primary care physicians.

Suggested solutions mostly deal with the compensation issue: putting more money in the pockets of primary care physicians will solve the problem. While compensation is an easy way to crystallize the issue, I believe it is only half of the problem. A complicated billing and coding system requires doctors to evaluate the value of each patient visit based on the complexity of the patient’s problem to justify the value of the visit for payment purposes, as opposed to the health care value of the consultation. One of doctors’ greatest fears is the audits and reviews by third party payers that often find that the doctor "over coded" claims and must refund money back to the insurance company. This creates an extremely unpleasant and often hostile environment for primary care and indeed all physicians.

Whatever the reason for the shortage, something must be done to change the system so that adequate primary care resources are available. In the next several blog posts, I will address the questions posed above and offer a possible solution.

Integrative Medicine Is Mainstream

The January 9, 2009 edition of the Wall Street Journal contained an opinion piece penned by Deepak Chopra, Dean Ornish, Rustum Roy, and Andrew Weil entitled "Alternative Medicine Is Mainstream". The authors are some of the biggest names in promoting alternative, complementary, and integrative medicine. The piece opened with the words: "The evidence is mounting that diet and lifestyle are the best cures for our worst afflictions."

President-Elect Barak Obama stated during his campaign: "This nation is facing a true epidemic of chronic disease. An increasing number of Americans are suffering and dying needlessly (italics mine) from diseases such as obesity, diabetes, heart disease, asthma and HIV/AIDS, all of which can be delayed in onset if not prevented entirely."

According to the authors of the Journal article, "The latest scientific studies show that our bodies have a remarkable capacity to begin healing, and much more quickly than we had once realized, if we address the lifestyle factors that often cause these chronic diseases. These studies show that integrative medicine can make a powerful difference in our health and well-being, how quickly these changes may occur, and how dynamic these mechanisms can be." Because of this statement and others, I am optimistic that the incoming administration recognizes that we must provide incentives for healthy ways of living rather than paying for only conventional drugs and surgery. In fact, in the long run, the only way we can make adequate health care available to the 45 million Americans who do not have health insurance is to focus on the fundamental factors that lead to both health and illness. Hopefully, this change in emphasis will be a key component of any forthcoming health reform legislation.

Another strong sign of the integrative medicine movement going mainstream is the recent opening of the Osher Clinical Center at Brigham and Women’s Hospital. The strong acceptance of the integrative approach by a mainline Harvard teaching hospital provides a ringing endorsement for integrative medicine. In fact, the cover story in the Fall 2008 edition of "The Magazine of Brigham and Women’s Hospital Boston" features the Osher Center. A key message in the story is the following: "Up until a few years ago, "alternative," or more commonly named " complementary" therapies were not provided at top academic medical centers such as BWH. But scientific research and clinical experience indicates that these treatments, some of which have their roots in Eastern medicine, do indeed offer viable and measurable medical benefits."

The Marino Center has been developing and providing integrative health care for over 15 years. It appears that these pioneering efforts are paying off through higher levels of utilization and public recognition of these treatment modalities’ efficacy.

On The Front Lines of Integrative Health

The purpose of this blog is to engage in a dialogue about improving our healthcare system from the perspective of keeping people well and treating illness in a manner that reduces the need for major and costly medical interventions. I will offer some of my own diagnosis and prescriptions for our ailing healthcare system and would welcome comments and feedback. I look forward to contributing to the coming transformation that must happen to save our healthcare system and the overall U.S. economy. To learn more about the Marino Center, visit our website: www.marinocenter.org.