Charting the Mainstream
A Review of Trends in the Dominant Medical System
by John Weeks
Integration Strategies for Natural Healthcare
Are
Health Plans Ahead of the NIH (and AMA) in Respecting the Science behind
CAM?
The widely-reported NIH Consensus Conference on Acupuncture (November
2-4, 1997) created a strong scientific footing for the mainstreaming
of acupuncture in the United States. The panel's findings are listed
in the left column of the table below. Interestingly, this list closely
resembles that guiding the acupuncture utilization management plan developed
a full two years earlier by Group Health Cooperative of Puget Sound
(GHCPS), a leading HMO covering 500,000 lives. (The right column.) Group
Health developed its plan through a lengthy internal process, initiated
in 1993 in response to member interest, and based on provider input
as well as a survey of the available literature. The list was published
when the plan offered its alternative benefit under the state's "every
category of provider" mandate.
COMMENT: Health plans which are beginning to cover
alternative benefits are regularly abused by spokespeople for conventional
medical science for throwing science to the wind by merely catering
to the consumer marketplace. A representative treatment was in American
Medical News article entitled "Patient demand often outweighs science
in coverage rulings" (November 25, 1996) and covered in this column
in May of last year. Steven Sheingold, PhD, director of technology and
special analysis for the US Health Care Financing Administration is
paraphrased as saying: "There is a growing battle between economics,
politics and patient advocacy on the one hand and evidence-based decision-making
on the other."
As the chart implies, the battle may be of a rather different nature.
For the health plan, in this case at least, appears to be the first
to have honored both patient advocacy and the science that exists. Conservative
medical science may be throwing science to the wind - as well as the
consumer - while catering to its own prejudice that "there is no
science behind CAM." The Group Health process for working with
acupuncture epitomizes that of the more thoughtful plans. First, the
consumer's interests are heard. Second, the providers of the CAM services
are consulted. The providers, in this case leaders of the acupuncture
profession and acupuncture schools in Washington state, are asked to
provide any evidence of scientific support. The providers may ask the
plan to look beyond JAMA and the New England Journal of Medicine for
useful research. A coverage or integration plan is then developed based
on these inputs. Laura Patton, MD, clinical director for alternative
services for GHCPS, commented at presentation at the Washington Health
Policy Conference in Seattle on December 3, 1997: "There does not
appear to be a vast gulf between what consumers are getting, providers
are providing, and what the evidence shows."
This subject cannot be left without recalling that the AMA Report on
Alternative Medicine issued by its Council on Scientific Affairs last
summer failed to acknowledge the research base for acupuncture (CSA
Report 12-A-97). Virtually all of the acupuncture research available
to the NIH group was available to the AMA investigators. This so-called
"scientific" council felt it necessary to include the following
which effectively slandered the acupuncturists: "Critics contend
that acupuncturists, including many traditionally trained physicians,
merely stick needles in patients as a way to offer another form of treatment
for which they can be reimbursed, since many insurance companies will
do so. Critical reviews of acupuncture summarized by Hafner and others
conclude that no evidence exists that acupuncture affects the course
of any disease." (pages 9-10).
This, one might say, is the last needle in the coffin of the AMA's
scientific or moral authority on these matters.
"In Defense of the Science Behind Alternative-friendly Benefits"
by (yours truly) John Weeks. Alternative Medicine Integration and Coverage
(St. Anthony Publishing, Reston, VA), December 1997, page 1.
Report
Shows Growing Popularity of Alternatives Among Canadians
A September/October 1997 report by the Angus Reid Group entitled "Canadians
and Alternative Medicines and Practices" found that 42% of those
surveyed had used "an alternative medicine or practice not usually
prescribed by conventional doctors." Close to half said their use
began in the last five years. Top categories among users were chiropractic
(59%), herbology (23%), acupuncture (22%) and homeopathy (18%). The
report was conducted on 1,200 adults from across Canada. Use is expected
to increase. Other selected findings were:
Source: The Angus Reid Report, Sept./Oct. 1997
Now
I know all you folks have the right kind of employers: Billiards in
Benefits Plans
To boost worker morale and stimulate productivity, more companies are
adding billiards to company recreation programs. One quoted employee
says: "It gives you a shared experience, either winning or losing.
It puts you a little bit more at ease with the people you're working
with and people from the other departments who play on teams."
Pool is played by more people than golf, touts the American Poolplayers
Association (APA), which has begun targeting "corporate development."
COMMENT: This little story casts some light - if obscurely
- on what is moving increasing numbers of health care purchasers and
payers to investigate integration of alternative medicine into benefits
plans. Pool as stress reduction. (Shoot, even science says a little
alcohol can be okay, no?) Pool as community building. It's wholistic!
And hey, the APA argues that pool can be played in-doors all year around
and employers don't have to buy shirts and equipment or pay for umpires.
River City has changed. Here we see employee satisfaction, cooperation,
effectiveness in work and even cost-effectiveness. With a capital T
that rhymes with P that stands for Éproductivity.
"Bonding through billiards boosts employee morale" by Craig
Gunsauley. Employee Benefits News, September 1, 1997, page 11.
Physician
Frustration with Care Delivered under Capitated Contracts
A study reported by Eve Kerr, MD, MPH, Veterans Affairs Center for
Practice Management and Outcomes Research, Ann Arbor, Michigan, provides
data on the chaffing of physicians under capitated payment schemes.
The survey of 910 California primary care physicians found that 71%
were very satisfied or somewhat satisfied with physician-capitated patient
relationships, versus 88% for doctor-patient relations in their overall
practice. Sixty-four (64) percent were satisfied with the quality of
capitated care delivered, versus 88% overall. Barely half (51%) felt
that they were able to provide care which suited their best judgment,
compared to 79% overall. Interestingly, the lowest differential between
capitated care and overall feelings was in an area which has received
substantial attention, the ability to obtain specialty referrals: 50%
versus 59%. Another finding was that physicians paid on salary tended
to be happier than those paid only on the basis of capitated payments.
COMMENT: From a CAM perspective, it is worthwhile
to note that the baseline (overall practice) below which these even
more depressed numbers are registering is an average 7-12 minute office
call. The physician's idea of "satisfaction" must have already
eroded in the baseline.
"Giving capitated care called less satisfying" by Peter Modica.
Medical Tribune for the Family Physician. September 4, 1997, pages 1,4.
Purchasers
Are Driving Health ReDeform
John Erb heads up the annual, statistically-balanced, study of employer
benefits which the Foster-Higgins consulting group (now part of William
Mercer, Inc.) has produced the last 11 years. The report is viewed as
a key resource in understanding purchaser behavior. Erb showed that
movement toward HMOs from fee-for-service, now at 27%, held steady between
1996 and 1997 after showing substantial increases from a minimal share
of the market in the early 1990s. Despite all the talk of the importance
of outcomes, only 25% of large employers (over 500 employees) ask for
outcomes in making their choices of health plans: "Our data does
not reflect a huge effort in surveying or outcomes." The major
recent shift has been to drop coverage of retirees. Since 1993, the
percent of large employers covering retirees under 65 has gone down
from 46% to 40%, and retirees over 65, from 40% to 33%. Employers are
also shifting coverage toward Medicare-risk plans which substantially
limit an employers financial exposure. There also is a growing trend
to not cover dependents. Stated Erb: "Employers aren't grouping
together to do anything. The only thing they grouped together to do
in the last five years was to limit retirement coverage."
COMMENT: Many observers of what is called "health
reform," including this one, have spoken of the purchaser as a
driver of health reform. This was a core concept in the Clinton strategy.
The idea was to get plans producing like data, so that purchasers could
make evidence-based decisions on which plans to choose for their employees.
This disturbing data leads to the conclusion that if the purchaser is
driving, it is health deform we are witnessing; or, alternatively, no
one is at the wheel as the vehicle simply rolls down the ramp into the
lake. Erb opined passionately about how criminal it is, in a nation
as wealthy as ours, that anyone should have to go without health care.
In short, the private sector is requiring the federal govern-ment to
take the lead.
Presentation by John Erb, William M. Mercer, Inc., at the Washington
Health Policy Conference, December 3, 1997.
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