Charting the Mainstream
A Review of Trends in the Dominant Medical System
by John Weeks
1)
First Report on Use of Alternatives Managed by HMO: High Member Satisfaction,
Possible Savings
The first data on HMO member experience of alternative medicine benefits
managed by an HMO was recently reported. The survey was carried out
by Alternare of Washington, a business which credentials alternative
providers for HMOs. The presenter was Laura Patton, MD, clinical director
for alternative medicine at one of Alternare's clients, Group Health
Cooperative of Puget Sound. The data was based on a survey mailed in
September 1997, of all of GHCPS members (n = 492) who had used acupuncture,
naturopathic or massage benefits offered by the HMO in the month of
May of that year. The survey included seven questions. Sixty-two (62)
percent responded. Some results are below.
Measured Result
Had condition for longer than 1 year 76%
Care from CONVENTIONAL physician for the condition was "very"
(16.5%) to "moderately" (29.9%) helpful 46%
Care from CAM provider was "extremely" (51.9%), "very"
(25%) or "moderately" (12.4%) helpful 89%
Perceived a "slight" (25%) or "substantial" (24%)
decrease in use of "conventional medical team" 49%
Perceived a "slight" (26%) or "substantial" decrease
in use of prescription medications 56%
Would "definitely" (70%) or "probably" (15%) return
to the same CAM provider with the same condition if they had to "do
it all over again" 85%
Patton noted that the data on both satisfaction and possible cost-implications
is only suggestive, and must be viewed over a longer term, and against
actual utilization, to be more definitive.
COMMENT: The data - while suggestive - should prove immensely
useful to the integration process. In a longer report on this data I
prepared for the February issue of Alternative Medicine Integration
and Coverage (St. Anthony Publishing, Reston, VA), I asked some experts
for comments on the value of the data. Richard Cooper, MD, head of the
Health Policy Program at the University of Wisconsin School of Medicine,
and an expert on provider supply, noted one possible long term outcome
succinctly: "This study and more like it may have important implications
for future staffing patterns of health plans, collaborative clinics
and health care organizations." Kenneth R. Pelletier, PhD, MD (hc),
co-director of the Complementary and Alternative Medicine Program at
Stanford, referencing the one-half of patients who were at least "moderately"
pleased with their conventional care, stated: "Many people using
CAM are not antagonistic toward mainstream care. It's just not enough.
People are just saying that mainstream care is not quite adequate."
"The Role of the Consumer in Coverage Decisions," Washington
Health Policy Forum, Seattle, WA, December 4, 1997.
2)
Mean Cost Per Chronic Condition for Conventional Treatment: Can Alternatives
or Integrated Care Do it More Cheaply?
Group Health Cooperative of Puget Sound (GHCPS - see article reviewed
above) published a report showing mean costs per specific chronic conditions
for its conventional care of its HMO members. These are as follows,
based on 1992 age-adjusted data:
Condition/Cost
Facial pain $4,088
Resp. disease $6,554
Back/neck pain $4,226
Diabetes $6,665
Headache $4,989
Mult. sclerosis $7,030
Arthritis $5,201
Pregnancy $7,412
Hypertension $5,649
Heart disease $7,626
Anxiety $5,713
Cancer $8,992
Depression $5,990
Dementia $9,842
GI disease $6,097
HIV infection $10,24
Panic disorder $6,107
Stroke $13,139
The mean annual cost of care per patient for the HMO was $2,006. For
those without chronic conditions, the figure was $924, with one condition,
$2,346; for those with one or more $3,992; for two or more, $7,019.
The researchers concluded that "efforts to control the amount of
and rate of growth of US health care costs should focus on how care
is organized and delivered to persons with chronic conditions."
COMMENT: This study has tremendous value as a tool for calculating
where and how complementary and alternative medical services may be
most cost effective. CAM providers must develop comparative global data
- which includes not only the cost of successful outcomes, but also
total costs incurred by those patients who are referred for more expensive
procedures or surgeries.
Credit GHCPS for making data available from both projects. The HMO
has the beginnings of data to look more closely at the next step toward
better integrating care and capturing some of the value for its members,
and its bottom line. Word on the street in Seattle is that the HMO is
actively investigating how it might include non-conventional services
into some of its practice guidelines.
"Chronic Care Costs Are Analyzed at Major HMO" in The Digest
of Managed Care, Vol. 1, No. 2, November 1997. From Health Affairs,
Vol. 16 (3), 1997; 239-47.
3)
Coverage of "Alternative Medicine" Climbs in Employer
Poll
The 1997 Business and Health Executive Opinion Poll showed a marked
increase in interest in alternative medicine among respondents, according
to a report in the December issue (pages 36-41). Increases are particularly
marked among large employers (respondents with over 500 employees).
These figures reflect a "catch-all" category, including such
services as acupuncture, massage, meditation, naturopathy, biofeedback
and body-mind interventions. The category does not include coverage
of chiropractic, which was a separate question. The findings are below:
1996/1997
All respondents 7% 16%
Over 500 employees 8% 24%
Business in Health is a monthly magazine published by Medical Economics
which targets employee benefits personnel. The surveys, completed by
phone and by mail, were of a "nationally representative" sample,
in three categories: 2-19 employees, 20 to 499, and over 500 employees.
Interestingly, chiropractic coverage was down slightly. In 1996, the
figure was at 58% for all respondents and 72% for large employers. The
corresponding findings for the 1997 poll were 53% and 71%. Other findings
of note are that 21% of all employers still do not cover prenatal care,
despite its clear benefits, with a similar percent not covering mammograms.
Prevention programs such as smoking cessation, weight loss, and onsite
screenings targeting risk reduction remain outside most benefit designs.
In each case, only about one-in-ten employers has ever offered such
programs. Interest is significantly higher among large employers.
COMMENT: The positive response on alternatives may be merely
a function of the present economic climate, which is a seller's market,
as far as labor goes, stimulating businesses to add sweeteners to their
benefits packages. Yet imagine you are an insurer. You learn that between
16-24% of your client pool may be asking for some sort of alternative
medicine coverage. Would your inclination be to write off this potential
business? Or respond to it?
4)
Thumbs-Up/Thumbs Down from FPs on Direct to Consumer Ads by Drug Companies
An American Academy of Family Physicians-sponsored survey found that
family physicians generally disliked the growing practice of direct
to consumer advertising (DTCA) by pharmaceutical companies. Of 454 respondents,
89% said they did not think the ads enhanced doctor-patient relationships.
Seven in ten (71%) thought the ads pressured doctors to use drugs they
don't ordinarily use. The main physician concerns were over false hope
and misleading, biased claims. On the plus side, 60% believed the ads
encouraged patients to take a more active role in their own health,
and 56% thought patients might come in for treatments that might otherwise
have gone untreated. DTCA spending rose to $610-million in 1996 from
$345-million the previous year. A spokeswoman for Glaxo Wellcome is
quoted with a position held by the advertising pharmaceuticals that
they are enhancing the doctor-patient relationship by giving patients
information "so they can go in and have an effective conversation
with their physician and healthcare provider." An industry survey
showed that the percentage of physicians, of all types, who were "very
likely" to prescribe a requested drug rose to 19% in 1996 from
13% in 1989. An editorial in The Journal of Family Practice which carried
the study (1997; 45; 495-499) did not come down strongly for or against
the practice.
COMMENT: DTCA by pharmaceuticals is an interesting practice
on which to meditate, given the fact that natural medicine advertisers
(through advertising support of such magazines as this one, Natural
Health, Let's Live, New Age, etc.) are arguably the main "educational"
interest which has been shaping the public's view of natural remedies.
In both cases, the consumer may enter a practitioner's office pre-disposed
to a certain treatment. Those in the alternative community are likely
to scoff at whether the pharmaceutical companies are actually acting
in the interest of the consumer. On the other hand, the conventional
medical community has been prone to tirades against the intentions of
"the vitamin pushers" for years. Can one in good conscience
be for DTCA in the one case, and not the other? Is this move, for whatever
the reason, in the long-term interest of creating a more empowered and
involved consumer? How is DCTA different than the parallel strategy
by the pharmaceuticals to make more drugs directly available to consumers
over-the-counter? Time will tell.
This pharmaceutical "detailing" of the consumer (better called
"broad-brushing" in this case) may be viewed as yet another
powerful jack-hammer aimed at the crumbling pedestal of the conventionally
oriented physician. Beset already by a growing body of consumers citing
strange-to-them data about alternatives, DCTA's by pharmaceutical companies
challenge whether these physicians are any longer the trusted masters
of their own, more familiar homes.
"FPs dislike direct-to-consumer ads" by Jody Charnow. Medical
Tribune (Family Physician Edition), January 22, 1998; 1, 4.
5)
Alternative Dressing (Neither Newman nor Divine...)
Dress codes at work in the United States are changing. A study by Bruskin/Goldring
OmniTel found that 70% of working people are now allowed to dress casually
"once or more per week." One-half report they can dress casually
any day, but for 7% of men and 16% of women, it is only once-per-week
through such practices as "Casual Friday." Thus 30% are still
not allowed to dress casually at all. Some employees are reportedly
attempting to "turn-the-tables" by promoting "Dress-up
Friday," leaving the rest of the week for casual dress.
COMMENT: The medicinal effects of this change are many. Diminished
stress (less how do I look? and how can I pay for the clothes?) Then
there are a multitude of de-toxifying and de-stressing benefits relative
to dry-cleaning: fewer costs (which has always seemed should be a deductible
business expense), fewer headaches of running things to-and-from, and
the limiting of chemical ingestion, both by individuals wearing clothes,
and the broader ecosystem. Then there are the unpinched necks (free!
free! free at last!). Millennial visionaries who see a vast new healing
energy spreading across the earth might add this study to their evidence.
This report is filed from a home office, where the dress code - like
in many such establishments spreading across America - is not "what"
but "if"...thus, in a small measure, manifesting utter enlightenment.
"Dressing Down at Work" in Managed Care Innovations, a publication
of NCMIC, a chiropractic malpractice insurance company. Summer 1997,
page 3.
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