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.