Holistic Nurse-led Integrative Medicaid Pain Pilot “Off the Charts” in Savings … plus more

Holistic Nurse-led Integrative Medicaid Pain Pilot “Off the Charts” in Savings

“You’ve just got to keep cranking the data and eventually they’ll listen.” Such was the reflection of Richard Sarnat, MD, on the “unprecedented level of interest” he and his colleagues at AMI Group are seeing in their Integrated Chronic Pain Program. The proximal cause for Sarnat’s musings was a report of the outcomes of AMI’s Medicaid pilot project¹ through 2 managed care firms in Rhode Island: Neighborhood Health Plan of Rhode Island and United HealthCare of New England. Rhode Island initiated the program to address the problem of high-cost Medicaid members who were also typically high opioid users. The cost measure of most interest was use of the emergency room (ER). The program targeted individuals who had at least 4 visits in the prior 12-month period. AMI’s model is managed by a holistic registered nurse. Sarnat explains: “This group of patients is so complex, with all of the bio-psycho-social issues and behavioral health issues, that while it might have been economically attractive to use a less skilled professional, we find the services of the nurses are critical to what we are seeking to accomplish. They protect the quality and safety of the program.” The nurses triage the patients between self-care, primary care, and integrative services such as chiropractors, acupuncturists, massage therapists, and behavioral health practitioners. The outcomes, said Sarnat, were “off the charts”:

• Medical costs: Reduced per member per year total average medical costs by 27%.

• ER visits: Decreased the average number of ER visits by 61%.

• Total prescriptions: Lowered the number of average total prescriptions by 63%.

• Opioid scripts: Reduced the average number of opioid scripts by 86%.

• Savings: Every $1 spent on complementary and alternative medicine services and program fees resulted in $2.41 of medical expense savings.

Sarnat says the data has been “validated by major third party independent reviewers.” AMI is currently in discussions with multiple parties in Rhode Island about expanding the program and, nationally, it is in significant discussion with 10 major payers for possible contracts. “Right now,” he adds, “there is a greater receptivity [to integrative pain treatment] than at any point in our 20 years. This is so different than it used to be. Everyone buys in now to the interdisciplinary model. Instead of general opposition, we just need to find a work-around for the remaining medical bias. We’re seeing a real sea-change in the environment.”

Comment: Chicago-based AMI is a rare business in the integrative medicine space for which the business model is data driven. The firm has previously published evidence of similarly astounding savings through an integrative primary care offering through HMO Illinois² and via prior Medicaid pilot through Florida’s Agency for Health Care Administration.³ Both sets of findings suggested rapid uptake and expansion of the models—but it was always somewhat mystifying that neither happened. Here’s hoping that this “sea-change” will result in more adoption this round.

Chiropractors Lead Campaign to Change the Nation’s Therapeutic Order in Pain Care

After the Institute of Medicine published its most influential report, To Err is Human,⁴ identifying the high level of morbidity and mortality associated with the regular practice of medicine, the quasigovernmental agency quickly followed with Crossing the Quality Chasm.⁵ The first was largely diagnostic, the latter prescriptive of how to resolve the identified problems—such as the abusive nature of the hierarchical care delivery environment. Pain treatment in the United States, and particularly the epidemic of opioid overuse and abuse, is in a parallel moment. A series of policy documents have identified the critical need to shift away from opioids toward nonpharmacologic and integrative approaches. The Centers for Disease Control and Prevention, for instance, was among those that boldly stated that nonpharma approaches should be used first. Yet these reports poorly engaged the policy guidance needed to make these recommendations stick.

A white paper released in a major National Press Club event on March 13, 2017, stepped into the prescriptive challenge.⁶ “It is a fact,” writes an author team that included Gerard Clum, DC, and William Meeker, DC, MPH, “that a chasm exists between the worlds of pharmacologicbased management of pain, and the non-pharmacologicbased management of pain.” While the paper’s title is profession-centric—“Chiropractic: A Key to America’s Opioid Exit Strategy”¹⁸—the core of the recommendations from the document offered through the Foundation for Chiropractic Progress are not just for chiropractic, but all nonpharmacologic, integrative approaches.

ShortTakes.

• A report on the Veterans Administration’s integrative Opioid Safety Initiative (OSI), launched in 2013, found that those on opioids dropped from 679 000 in 2012 to 471 000 in 2017, with reduction in those on long-term opioid therapy dropping by an even greater margin, from 122 000 to 53 000, or 56%. The proportion of all patients with any pharmacy use who received opioids fell from 17.2% to 11.6%.⁷ Under the OSI strategy, veterans have access to various integrative methods including chiropractic, acupuncture, and mind-body.

• The Natural Products Association is prioritizing a campaign to “Tell Congress to Cover Dietary Supplements in HSAs & FSAs to Improve Access and Lower Costs for Americans.”⁸ Health Savings Accounts have typically been a priority in Republican proposals.

• The American Chiropractic Association named Anthony Lisi, DC, as Chiropractor of the Year. Lisi is the director of chiropractic services for the Veterans Health Administration where his diplomacy and clinical leadership has continuously expanded and anchored a program that was originally forced on the agency by Congress.⁹

• In another in a recent string of losses of major institution-based integrative centers, the Mt Sinai merger with Continuum Health shut New York’s integrative medicine “crown jewel,” the Continuum Center for Health and Healing.¹⁰

• American Botanical Council founder Mark Blumenthal was recognized by the Society for Ethnopharmacology–India with its Outstanding International Ethnopharmacologist Award for 2017.¹¹

• The Maryland University of Integrative Health’s (MUIH’s) Steffany Moonaz, PhD, travels regularly to Congress to teach mindfulness to members and their staff as part of Congressman Tim Ryan’s campaign to enhance understanding and practice of mindfulness in Congress.¹²

• Also at the multidisciplinary MUIH, Steven Combs, PhD, was chosen as the new MUIH president and chief executive officer. He succeeds Frank Vitali.¹³

• Trump nominee to head the Food and Drug Administration, Scott Gottlieb, MD, affirmed a traditional view of vaccines, distancing himself from the Trump-Kennedy initiative to explore vaccine science and risks that was reported here in the last issue.¹⁴

• One marker of decay in the medical industry is physician burnout. The NEJM Catalyst documented the sad trend in “Leadership Survey: Why Physician Burnout Is Endemic, and How Health Care Must Respond.”¹⁵

• The Academic Consortium for Integrative Medicine and Health has named Heather Tick, MD, to head up their key policy engagement, on opioids. Tick and her team will focus on dissemination of “evidence-informed information and resources on the nonpharmacologic treatment of pain.”¹⁶

• An unusual conference in Colorado explored the potential of integrative medicine as a factor in helping the campaign of the state’s government, John Hickenlooper, to make that state the nation’s healthiest. Leading to conference was Integrative Health Policy Consortium chair Len Wisneski, MD.¹⁷

The paper describes the chasm: “Unfortunately, beyond asserting the need to move in this direction, little, if any, guidance has been offered to providers, patients and payors on how to accomplish this important transition.” The authors continue: “The focus needs to shift to early applications of non-pharmacologic approaches first and not as a follow-on after the drug path has been established.” Similarly: “As a non-pharmacologic approach to effectively address acute, subacute and chronic non-cancer pain, integrative care management answers the needs of individuals nationwide.” The major culprit the authors identify is the lack of appropriate payment strategies. Hand-in-glove with this principal shortcoming is the failure to develop educational programs for consumers and practitioners to advance awareness of options to opioids, and to promote changes in patient management.

Comment: The chiropractors are, by far, the most politically engaged of any of the organized professions reflecting integrative pain management. So, it is pleasing to see the field reach a level of maturity in which it is no longer merely elbowing a way forward for its own members. Instead, with this white paper—despite its more limited title—the chiropractors are standing up as leader on an important need in health care: to reorient toward more conservative care. In this paper, they are standing forward as representatives of an “exit strategy” from opioid reliance that is inclusive. Now, time for them to figure out how to forge alliances with the American Medical Association, the American Society, of Anesthesiologists, the American Pain Society and others who have identified payment as the chief obstacle,¹⁹ but who have not yet prioritized methods to change policy. These could through a little clout behind this critical step for the exit campaign.

Casey Health’s Integrative Primary Care Medical Home “Bending the Cost Curve”

The nation’s most significant pilot project for a fully integrative primary care medical home (PCMH) is Gaithersburg, Maryland’s Casey Health Institute (CHI). When philanthropist Betty Casey presented David Fogel, MD, and Ilana Bar-Levav, MD, with an opportunity to engage a significant integrative medicine venture, the two determined to create a model that would become a national resource. Their strategy: Model their clinic as a PCMH and embed their delivery in an accountable care organization (ACO). The goal: Let their integrative outcomes be measured in the medical home and accountable care coin of the realm established under the Affordable Care Act.

In recent report on outcomes that also notes that the Institute had a visit from US Surgeon General Vice-Admiral Vivek Murthy, MD, MBA, indications are now public that Casey Health Institute appears to indeed to be “bending the cost curve” with their model.²⁰ Some recent data on their care of 5000 patients in 16 000 visits:

• Hospital stays per 1000: Outperforming Center for Medicare and Medicaid Services (CMS) targets, was the fifth-best PCMH in the ACO, with 19% fewer hospital admissions than PCMH peer practices.

• 30-day readmission rates: Outperforming CMS targets; was first in CHI’s ACO; also 19% fewer than CHI’s PCMH peer practices.

• Pharmaceutical costs: CHI patients’ pharmacy costs per member per month (PMPM) were 29% less as compared with PCMH peer practices (CHI, $51.13; PMPM/PCMH peers, $72.11 PMPM).

• ER visits: CHI patients visited the ER 14% fewer times compared with PCMH peers (CHI, 188; PCMH peers, 217.5).

• Patient satisfaction: Above the national benchmark, with 98.4% reporting that they would refer friends and family to CHI for their care.

Casey Health Institute’s client based is 70% female, 66% white, has 62% patients aged 35 to 64 years, and has the following chief diagnoses: pain (40%), anxiety/hypertension (17%), diabetes related (15%), hyperlipidemia (12%), and hypertension (11%). Its interprofessional team includes integrative medical doctors, licensed acupuncturists, a naturopathic physician, a chiropractor, holistic nurses, yoga therapists, nutritionists, psychologists, massage therapists, a cooking center, group services, and more. In the interview, Fogel shares that he envisions the area becoming a “Blue Zone” with CHI a hub. He has begun meeting with leaders of the local Chamber of Commerce and the municipality of Gaithersburg to talk up the idea.

Comment: A 2014 survey found that the context of accountable care and medical homes offers an apparent alignment²¹ with integrative health and medicine principles and practices. Fogel and Bar-Levav have smartly put Ms Casey’s resources in the service of proving this postulate. These early data suggest they are on the right track. It is unfortunate that we are not yet seeing significant investment from other sources to begin sprinkling these PCMH’s across the landscape. More information on the Casey Health model is at the Center for Optimal Integration website of the Academic Collaborative for Integrative Health.²²