By Mary A. Shaub, M.H.S.
Faced with making strategic business decisions in the era of shrinking insurance reimbursement, conventional doctors are considering alternative revenue streams. Complementary alternative medicine (CAM) is one of them. CAM includes such therapies as acupuncture, homeopathy, massage, chiropractic services, aromatherapy and spiritual healing. Some of the modalities are ancient; acupuncture has been used for 2500 years.
Traditional physicians have been cautious in embracing these methods, citing lack of clear empirical evidence as to their safety and efficacy. If carefully examined, CAM could be the answer to your practice’s shrinking revenues. This article’s intent is to help you to begin the process. It will supply the reader with data on CAM’s revenues and utilization since 1990, trends in the government, scientific and educational environments, considerations for integrating CAM into your practice and two different integrative approaches. Let’s examine the latest statistics.
The Journal of the American Medical Association (JAMA) has recently reported that revenues from CAM will top $34 billion. This is a 300 percent increase from 1993’s out-of-pocket expenditures of $13 billion. Researchers from the Harvard Medical School found that by age 33, seven out of ten people who were born between 1965 and 1979 had used some form of CAM. Fifty percent of Americans aged 35 to 49 used at least one form of CAM remedy. With 629 million visits in 1997, this field experienced a 47 percent increase from 1990 when 427 million visits were recorded. This demand has inspired the government and educational facilities to create programs and promote scientific investigation.
From the government’s perspective, it is clear that CAM is here to stay. The White House Commission on Complementary and Alternative Medicine, established during the Clinton administration, urged the Centers for Medicare and Medicaid Services to fund demonstration projects involving CAM. Medicare policy currently allows coverage of chiropractic services.
To promote scientific efforts, the National Institutes of Health (NIH) formed the Office of Alternative Medicine in 1993. In 1998, NIH created the National Center for Complimentary and Alternative Medicine to conduct and support applied research and training in CAM. To obtain information regarding their efforts, go to their website at http://nccam.nih.gov.
The Hopkins Internist, in November 2000, highlighted a five-year NIH award of $7.8 million to The Johns Hopkins Center for Complementary and Alternative Medicine. Designated to study alternative therapies for cancer. This project will adhere to the empirical standards used in other clinical trials at Johns Hopkins such as double-blinded placebo studies. This center’s studies and educational opportunities can be accessed through their web address, www.hopkinsmedicine.org/cam.
Through January 2002, JAMA has published 200 articles discussing CAM. An Australian study illustrated the positive response of Chinese herbal formulations to treat irritable bowel syndrome. The University of Pennsylvania’s School of Medicine reported that patients with carpal tunnel syndrome who participated in an eight-week yoga program improved more than patients who received only a wrist splint. Researchers at the Minneapolis Veterans Affairs Medical Affairs Center said saw palmetto, an herbal remedy for symptoms caused by an enlarged prostrate, is about as effective as the drug Proscar in relieving symptoms and increasing urine flow and had fewer adverse side effects than the drug.
Educationally, JAMA encouraged medical schools to offer training to physicians in CAM in its September 2001 issue. George Washington University, Harvard, and the Johns Hopkins University (JHU) are among the universities offering CAM courses to medical students. For those who prefer self education, JHU provides a CAM resource list via its medical library’s website at www.welch.jhu.edu/internet/altmed.html. This educational and scientific information will provide the foundation for incorporating CAM into your practice.
When integrating CAM, always include the following four factors. Survey your patients’ use of CAM. Learn about various CAM approaches so that patients perceive your accepting attitude. Develop referral relationships with CAM, and determine the best method of integration.
Soliciting information from the patient regarding their current use of CAM is important for treatment efficacy and patient satisfaction. Questions such as “What herbal remedies and prescription drugs are you using?” and “Who are your health care providers including your primary, specialists and CAM providers?” can be included on initial registration forms and as part of annual examinations. It is reported that only 38 percent of patients disclose using CAM to their physician.
Become your patients’ resource for CAM by researching techniques that you can endorse and are complementary to your treatment recommendations. Daily updates regarding CAM can be viewed at MSNBC’s website, www.msnbc.com. Researching the web and listing resources for patients demonstrates your acceptance of CAM to them. This comfort level is especially important for patients using of nutritional supplements and herbal medicines which can interact with traditional medications. The Physicians’ Desk Reference for Herbal Medicines and Physicians’ Desk Reference for Nutritional Supplements are useful reference guides for these CAM therapies.
CAM Referral networks will develop as your level of education and awareness increases. CAM’s professional associations are usually eager to formulate relationships with physicians who have common areas of interest.
The last consideration is the method of integration. The method with the lower physician liability and the lower financial impact is to refer patients to CAM providers. Incorporating CAM into your office service delivery system has the larger financial reward and has incrementally increasing risk. It can take the form of renting space to a CAM provider, hiring a CAM provider or learning a CAM technique yourself. Both methods are illustrated below. The first example shows the referral model and the second features a physician who learned a therapeutic technique.
Susan Budenstein, owner of Healthy Living Associates, in Philadelphia, PA has been providing massage treatment for 17 years. She uses massage therapy and movement re-education techniques to complement treatment provided by conventional doctors. Rheumatologists, Family Practitioners, Physiatrists and Psychiatrists refer her patients. Patients’ symptoms include joint pain, headaches, back and neck pain, chronic fatigue, fibromyalgia and stress. By using a variety of methods such as cranio sacral, shiatsu, acupressure, myofacial release, Budenstein’s treatments allow patients to have body better mechanics so they won’t reinjure themselves or preserve their current level of function.
Dr. Steven Grossinger, partner at Swarthmore Neurology Associates in Ridley Park, PA, is now offering patients acupuncture after completing a 300-hour continuing education course provided by UCLA. After learning that more people in history have been successfully treated with acupuncture than every other type of medicine combined, he wanted to offer this CAM to his patients. He felt that this would be a tool to treat the more frustrating clinical situations. Although he has treated most patients for pain, acupuncture has been used for patients with stroke, vertigo, fibromyalgia and tinnitus. Dr. Grossinger has embraced this eastern philosophy’s treatment which involves influencing flow of energy (“chi”) throughout the body. He states, “I have…been using acupuncture for treatment of headache, neck and back pain; mixing local treatment of muscle spasm and trigger points with approaches that move energy along the meridians.”
It should be evident that CAM’s impact on the health delivery system is significant. Billions of out-of-pocket dollars are being spent by consumers, researchers and educators annually. CAM’s reimbursement is not regulated by the insurers. Is it time your practice embraces the suggestions of Benjamin G. Druss, M.D., MPH and Robert A. Rosenbeck M.D., by endorsing CAM as an addition to and not the replacement of conventional medicine?
Mary A. Shaub, M.H.S., is president of Shaub Medical Benefit Consulting, based in Philadelphia, Pa.