Paradigm Change in Integrative Care: Third-party Payment and the Cost-benefit … Plus More

Introduction

The business of integrative health and medicine poses 2 challenges at the intersection with the dominant school of medicine. One is that the medical industry—in the still prevailing fee-for-service context—benefits from an increase in production of costly surgeries, drugs, and procedures. Thus, it is perversely incented against integrative approaches and practitioners that may reduce needs for these services. (See “AMA’s Celebration of MDs’ Economic Muscle Exposes Barriers to Integrative Health” in the last issue of IMCJ.) The second challenge, paradoxically, is that concern from these same decision-makers about potential costs that may be incurred is a barrier to access and inclusion of integrative practitioners providing nonpharmacologic services. This issue of IMCJ Industry News provides 3 angles of perspective on these cost issues.

An Actuary’s Guide to Paying Practitioners Who Can Reverse Chronic Disease

Ken Beckman is a rare actuary. After viewing and reading the lifestyle-oriented “Forks Over Knives,” he applied the book’s principles it to himself. Finding he could reverse his own chronic conditions, he developed a pilot product in his insurance company, Central States of Omaha. He showed a 20% reduction in use of medical services in a population of insureds after a similar intervention to the one he applied to himself: the Forks Over Knives book and a video, plus a letter suggesting the insureds who received it could reverse their chronic conditions.¹ Beckman’s certainty that chronic disease could be reversed provoked him to cofound the Actuaries for a Sustainable Health Care and to join the Economics Advisory Board for the American College of Lifestyle Medicine (ACLM).

Through his ACLM position, Beckman is promoting what he calls an “Actuarial Patient Value Model” for reimbursement of practitioners.² The model acknowledges that, over the long run, the business model for insurance companies is perversely incented against lowering medical costs. (See “The 80/20 Rule: Why Insurers Are Incented Against Lowering Costs [and Integrative Health].”³) The model rests on a partnership with employers, who are aligned with cost savings.

The other stakeholder partner on which Beckman’s model rests are the integrative, lifestyle, and functional medicine practitioners who believe they can reverse the process of high-cost chronic diseases. Beckman explains how it might work with reference to employees with diabetes. Data suggest that, on average, a diabetic patient with an HbA_1c of 9.0 will cost $15 000 per year. If that HbA_1c is reduced to 6.0, annualized costs in an actuarial model move closer to $7500. Beckman’s model urges that projected savings for the employer from reducing the risk of disease and maintaining a higher level of health be shared with the practitioners who partner with patients to successfully make the healthy changes. In Beckman’s model, for instance, the practitioner could receive a $2000 bonus (27% of the $7500 actuarially-estimated savings) each year, per patient whose HbA_1c maintains that drop from 9 to 6.

Comment: Beckman’s model evokes the story of ancient Chinese doctors who were purportedly paid for keeping people healthy rather than for providing services. Note these 3 characteristics of the model: (1) employer as partner; (2) belief in the ability of integrative practices to reverse chronic disease; and (3) the offering of shared savings to enrolled partners. Though organized differently, each is a characteristic of the Incenticare model described later.

James Maskell’s National Tour for the Incenticare Model to Pay Integrative Practitioners and Expand Access

James Maskell, the cofounder of the Evolution of Medicine-Functional Forum, is a nonstop communicator and marketeer. For the last half decade, he has been operating at the visionary, business edges of the integrative- and functional-medicine worlds. As this copy is being drafted, Maskell is on a 22-city tour in search of a trifecta for the field: (1) expanded reimbursement for integrative/functional practitioners, (2) increased access to integrative options for employees, and (3) cost-savings for employers. The centerpiece is an insurance product directed at employers called Incenticare. The product was developed by the Benicomp Insurance Company.⁴

ShortTakes.

• ► The Veteran’s Administration has announced its Whole Health Flagship Sites where the integrative health strategy led by long-time integrative medicine leaders Tracy Gaudet, MD, and Ben Kligler, MD, MPH, will be first promoted in a big way.⁵

• ► Lori Knutson, RN, BC-HN, will take a new position as the vice president of health and well-being at Duke University Health System where she will oversee Duke Integrative Medicine, the Duke Fitness Center, and the Duke Diet Center.

• ► In another sign of mainstream acceptance of integrative practices, the American Society for Clinical Oncology endorsed integrative breast cancer guidelines developed by the Society for Integrative Oncology. Work on the Society for Integrative Oncology (SIO) guideline was led by Heather Greenlee, ND, PhD.⁶

• ► Integrative Medicine for the Underserved held a Congressional briefing session on June 21, 2018, on nonpharmacologic approaches to serve the underserved.⁷

• ► The Alliance for Natural Health is declaring victory in its battle with the US Food and Drug Administration (FDA) to keep citizens and practitioners from losing access to compounded pharma products.⁸

• ► Also at the FDA, the National Center for Homeopathy has posted its response to the agency’s challenges to the homeopathic industry.⁹

• ► One of India’s wealthiest people, Subash Chandra, has opened a massive wellness center in New York.¹⁰

• ► The state of Oregon has made $250 000 available to students in the naturopathic program at National University of Health Sciences who dedicate themselves to service in underserved areas.¹¹

• ► The remarkable legacy in promoting inter-professionalism and team care of George Thibault, MD, who recently retired as chief executive officer of the Josiah Macy Jr. Foundation, includes breaking a glass ceiling that historically has separated large foundations from making grants for integrative health initiative.¹²

• ► A thorough scientific publication on a pragmatic trial examining the inclusion of acupuncture in Vermont’s Medicaid program has been published and is available via open access.¹³

• ► A new Veterans Health Association directive (1210) issued March 28, 2018, describes the remarkable advances that chiropractors have made in the Veteran’s Health Administration since Congress mandated inclusion in 2000.¹⁴

• ► Tabatha Parker, ND, has been named the interim executive director of the Academy of Integrative Health and Medicine (AIHM). Parker has previously had lead roles in AIHM’s conference and its growing Fellowship in Integrative Health and Medicine.¹⁵

• ► The Acupuncture Now Foundation and the National Certification Commission for Acupuncture and Oriental Medicine released a 30-minute documentary, available for free, on the role of acupuncture in the treatment of those with cancer.¹⁶

• ► The new chair of the Academic Consortium for Integrative Medicine and Health (“The Consortium”) is Rick Hecht, MD, a full professor at the University of California, San Francisco, School of Medicine.¹⁷

• ► Two new resources on the maturation of the integrative health movement are “Chronology of Integrative Health Inclusion in Federal Policy”¹⁸ and a list of “Major Collaborations of Integrative Health Organizations Toward Changing Policy and Practice: 2002-Present.”¹⁹

The distinguishing feature is a federal waiver that allows it to charge different levels of premiums per employee based on that employee’s health status. Thus, if the chronic disease shows signs of reversal, premium costs to the employer—and the employee for his or her share—can go down. The incentive in Incenticare is that Benicomp shares in the savings.²⁰

This is where the integrative doctor fits in. Via personal health experience of the services of functional medicine doctor and educator Jeff Gladd, MD, Benicomp Executive Doug Short came to believe that a version of integrative and functional medicine anchored by well-trained health coaches could reliably produce reversal. Benicomp contracted with Knew Health—a new entity promoted by Maskell for which Gladd, a graduate of the University of Arizona Fellowship in Integrative Medicine, serves as medical director. They are developing, when needed due to employer contracts, localized preferred-provider organizations of integrative and functional medicine practitioners. Gladd is working with health-coach educator Tracy Harrison to manage a team of health coaches and triaging employees, when appropriate, to coaching or doctor services. Meantime, Maskell’s tour is stirring interest among employers and of potential integrative practitioners. The Knew Health team is asking members of the functional and integrative community to help connect with their patients or networks to find potential employers. The incentive for practitioners is to create a steady stream of patients. Gladd notes that the PPO network will focus on credentialing practitioners whose focus is rooted in helping the employees make lifestyle changes “rather than expensive testing and a lot of supplements.”

Maskell’s aspirational goal is by January 2019 to have in place a PPO network of functional-medicine doctors making up to $300/hour for their roles in serving at least 5000 employees. Meantime, he and his colleagues are finishing a round of financing for EvoMed and Knew Health while anticipating a new, larger round of financing that might support this and other Knew Health plans. It will take a village—and some venture capital—to make this product roll. If it does, it could be a terrific vehicle for proving the integrative model.

Comment: There is much about this initiative to respect. The design is thoughtful. It rests on a core belief that integrative and functional medicine connected to a network of coaches can cost-effectively reverse chronic disease for an employee population. It’s a rare gambit to truly put what this field says it can do on the line. It’s also a way to create more widespread access to integrative care. Will the field step up and partner with Maskell, Gladd, and their Knew Health team?

Government Report: Covering Naturopathic Doctors Decreases or Minimally Increases Costs

Those searching for the financial impact of including the integrative care of naturopathic doctors in insurance plans can find answers in a government report from the state of Maine. The state’s Department of Professional and Financial Regulation (DPFR) surveyed Maine’s insurers who had previously covered naturopathic services: “Aetna and Anthem estimated the expansion of coverage under the amended bill [to mandate coverage of naturopathic care] to be cost neutral. Community Health Options and Harvard Pilgrim Health Care were not able to provide cost implications although Harvard Pilgrim Health Care stated that any cost increase would be insignificant. United Healthcare Insurance Company estimated a 0.1% increase to costs.” In addition, officials from Harvard Pilgrim Health Care upped the profession’s positive profile when it “indicated there could be potential savings in health care costs specific to certain conditions, particularly with regard to control of hypertension, obesity, and select chronic pain.” These are big-ticket items.

The DPFR also surveyed patients and examined available data and experience in other states. The theme of the special value of naturopathic doctors for chronic conditions reoccurs. Patients reported that “conventional treatment methods for chronic conditions were not successful so they pursued treatment from naturopathic doctors and had more positive results leading to a higher quality of life.” And again: “Providers such as naturopathic doctors provide a more integrative approach to medicine that may improve the quality of life for patients.” The overall conclusion: “We believe any increase in costs due to [adding coverage] would be minimal and if the services are a substitute for MD services, there may be a decrease in cost for some patients.”

The agency’s report was produced at request of the legislature during a campaign for a legislated mandate from patients of naturopathic doctors and members of the Maine Association of Naturopathic Doctors. Backed by the findings of the DPFR and an activist constituency, MAND—led by Anne Jacobs, ND, and Elizabeth Yori, ND—convinced the legislature to overturn a gubernatorial veto and make the mandate law.

Comment: A close look at this report reveals that this coverage of a naturopathic doctor’s practice is not very adventuresome. Neither the agency nor the legislature was much interested in thoroughly exploring what it is the patients are experiencing when they “feel that an ND can help them when conventional medicine has not.” Hopefully this initial coverage will one day open a transparent examination of the effect on the payment and delivery system of what patients find in the full expression of the naturopathic doctors’ polymorphic integrative approaches.