Policy

CPT royalties a bonanza for AMA

AMA's $70-million CPT royalty reported, attacked as subsidy for subjugating other disciplines

A recent report in the Integrator revealed that the political work of the American Medical Association (AMA) is subsidized to the tune of roughly $70-million each year through royalties from its ownership of Current Procedural Technology codes (CPT). Providers from all disciplines who accept 3rd party payment effectively pay into this AMA fund, despite the fact that the AMA opposes the advances of other disciplines, especially as independent practitioners. The Integrator report was prompted by

The IOM report on nursing, opposed by the AMA

The AMA position continues that of the 2006-present AMA Scope of Practice Partnership (SOPP) campaign through which the AMA supports opposition to scope expansions of other professions, including chiropractic doctors, midwives (nurse and direct-entry), psychologists, naturopathic physicians, optometrists, acupuncture and Oriental medicine practitioners as well as advance practice nurses. The AMA also opposes the anti-discrimination portion (Section 2706) of the Obama reform law. The AMA's control of the CPT also gives this guild the right to keep other disciplines from developing proper codes for their field. In addition, the AMA's CPT ownership gives the guild a special relationship to the US government relative to payment policy.

Comment: It is an astonishing confrontation with the past to imagine that such power was ever conferred on a single guild. The necessary transformation of US healthcare is toward diversity, multidisciplinary practice, collaboration, team-care, and respect for the skills of all parties. The movement is away from the still current MD-centric, patriarchal, top-down, father-knows-best world of Dr. Kildare. The response to the Integrator article has been, bluntly put, that enough is enough. (See 18 Views: Forum on the AMA's $70-million CPT Warchest Includes Calls for Action to End the Subsidy.) Says integrative nurse Kreitzer: "Let's end it.

Center for Public Integrity research reports AMA's "secretive" control of Medicare payments

The October 26, 2010 story in the Wall Street Journal is entitled

"Three times a year, 29 doctors gather around a table in a hotel meeting room. Their job is an unusual one: divvying up billions of Medicare dollars. The group, convened by the American Medical Association, has no official government standing. Members are mostly selected by medical-specialty trade groups. Anyone who attends its meetings must sign a confidentiality agreement."

Comment: Anyone wonder whether these old structures - CPT and RUC - might be getting in the way of reform? These two stories, both published October 26, 2010, are quite a pairing. The best comment on both is this reflection, relative to the CPT issue, from Lori Knutson, RN, BS-HN, director of integrative health care for Allina Hospitals & Clinics and the Penny George Institute for Health and Healing. Knutson writes here:

"Kudo's for bringing awareness to the presenting problem of the AMA/CPT code 'energy block' that has somehow covertly managed to stay quite hidden in the meridians of our dis-eased healthcare system.  Our ability to move this very important work forward does, at times, require exposing and experiencing the hidden devices of underlying cause.  Sometimes debriding is the right medicine.  I am sure that as the uprooting of our healthcare system unfolds there will be more surprises (learning's?).  Hopefully we have come to a point in our society that we realize its time to come together, let go, and remember "We the People" created this and "We the People" are obligated to make it right for the whole.

Comments on draft 2011-2015 strategic plan

AHMA, CRN, AAAOM,ACCAHC and NPRI weigh in on NCCAM's draft strategic plan

The now year-long process of public commentary and response on the development of the 2011-2015 strategic plan of the NIH National Center for Complementary and Alternative Medicine recently stimulated a new round of responses from key stakeholders. Published here are letters from the American Association of Acupuncture and Oriental Medicine, Council for Responsible Nutrition, Academic Consortium for Complementary and Alternative Health Care and the Naturopathic Physicians Research Institute. A perspective of David Forbes, MD, president of the American Holistic Medical Association is here. The most significant common response is to honor NCCAM for prioritization of "real world research" and the health-promoting outcomes of integrative interventions, but also to urge that this focus be elevated. Disclosure: I was involved in drafting the ACCAHC letter.

IHPC's Kahn: Advancing policy opportunities

Report on IHPC action on PCORI and workforce issues

McGarey: Taking on reform at 90

Gladys McGarey Medical Foundation releases 2nd "Gathering of the Eagles" policy recommendations

Gladys T McGarey, MD is known to many as a founder of holistic medicine. In recent years, she has twice convened gatherings of holistic medical leaders, through the Gladys Taylor McGarey Medical Foundation, to explore strategies to shift the paradigm of US medicine. The 2010 report is based on 2 days of work by a selected group of 60 "holistic physicians, nurses, medical researchers and other integrative providers." The recommendations in the report range from promoting wellness, supporting holistic pregnancy and birth, standardizing certification and licensing, and funding education and research strategies. The recommendations covered a broad arena, from changing conventional medical education to increasing research and practice and providing support for distinct fields such as naturopathic and homeopathic medicine. One unusual recommendation: "Recognizing Women as Important Healthcare Decision Makers." The report notes that women are estimated to make 80% of healthcare decisions. 

McGarey, energetic at 90-years-old, is making a series of visits to healthcare leaders in the Beltway in an attempt to foster the shift for which she has worked for decades. The reports from the 2009 Gathering of Eagles as well as those from the June 2010 meeting are anchored to President Obama's call for reform. One target: educating administrator Donald Berwick, MD and the Centers for Medicare and Medicaid Services about the value of integrative approaches.

Comment: A colleague from a decade ago, Terry Schmidt, DHA, linked me into the work of McGarey's team. McGarey's energy is enviable. I urged her team to appreciate that some terrific coalition work is underway -especially that noted above through the Integrated Healthcare Policy Consortium, Samueli Institute, The Institute for Integrative Health and the Palmer Center for Chiropractic Research. Hopefully McGarey's eagles will find ways to have their work dovetail with that of these organizations so power can begin to coalesce and who knows, perhaps prove effective! 

Integrative Centers

Article poorly portrays True North center

What SmartMoney said, what True North actually does

Maine's True North Healing Center recently sent out a press release following coverage of the clinic's method of care in an article entitled Medicine without Doctors in Wall Street Journal's SmartMoney. Rather than merely boasting the coverage, True North used the moment to describe the chasm between the media presentation

Comment: Funny, the WSJ writer started her "alternative medicine" bit that featured True North with 4 sentences discounting any evidence for such care, then proceeded to write an article which apparently was not evidence-based journalism. Credit True North for taking the lemons and making lemonade.

Cost Effectiveness

Guarneri: Headed Bravewell team on cost report

Bravewell publishes pamphlet on cost-effectiveness of integrative medicine

The Bravewell Collaborative of philanthropists for integrative medicine has published a new 16-page pamphlet entitled The Efficacy and Cost-Effectiveness of Integrative Medicine: A Review of the Medical Literature.  The authors are: Ermenia (Mimi) Guarneri, MD, Scripps Center for Integrative Medicine, Scripps Health; Bonnie J Horrigan, Bravewell's director of communications and public education; and Constance M Pechura, PhD, executive director of the Treatment Research Institute (TRI). The authors begin by indicating that

"A review of the medical, corporate and payer literature reveals that, to start, immediate and significant health benefits and cost savings could be realized throughout our health care system by utilizing three integrative strategies:

1. Integrative lifestyle change programs for those with chronic disease;
   
2. Integrative interventions for people experiencing depression; and
3. Integrative preventive strategies to support wellness in all."

.) Still, this little booklet, downloadable here, should prove useful in some environments.


Professions

Moore: Co-chairing effort to set health coaching standards

Harvard/U Minnesota leaders organize effort to set education and credentialing for health coaches

"Health and wellness coaching is the change agent that shifts the culture and delivery of health care from dependency to empowerment." So reads an aspirational poster from one of the working groups at the late  September summit to explore national standards and certification in the field of health and wellness coaching. In an October 20, 2010 release from the organizers,

Comment: Coaching, different than "education" or "counseling," deserves an elevated role in integrative practice. I shared my views on this subject in With Standards in the Works, Is it Time to Claim, and Certify, the Health Coach Within?  My perspective is not unanimously embraced. (See Chris Johnson, ND: "Disturbed" by the Positive View of Health Coaching in Integrative Practice.) Still, I believe that all integrative practitioners who claim that they help empower people have skin in this game.

NCBTMB's advanced certification seal

NCBTMB, massage certifying body offers "advanced practitioner" program

On October 8, 2010, the National Certification Board for Therapeutic Massage & Bodywork (NCBTMB) announced "continued progress" in developing its exam for the National Certification for Advanced Practice (NCAP). NCBTMB presents the initiative as "the first to enable accomplished (massage) practitioners to differentiate themselves in the massage marketplace." The agency suggest that the certification will also "make it possible for employers and members of the conventional and integrative healthcare arenas to hire practitioners based on a certified, advanced level of experience and expertise." "NCBTMB Chair Neal Delaporta is quoted saying that "the credential will open up new opportunities for therapists in conventional, integrative and clinical healthcare settings. It has the potential to take the entire profession to a new level within the medical community."

Comment: The idea of advanced certification has been floating around the massage community for some time. I asked 2 massage educator colleagues from the Academic Consortium for Complementary and Alternative Health Care (ACCAHC) for their perspectives. Jan Schwartz, MA, past chair of the Commission on Massage Therapy Accreditation, and an Integrator adviser writes:

Schwartz: Raises questions

"An advanced certification is needed in massage so that the public can tell the difference between therapists, but the question is how is 'advanced' defined?  For example, I went to a school that had 1000 hours of education. NCBTMB requires 500 hours of education to take the current certification exam. So does that make me advanced before I even start? (The answer is no. I was told my education was entry level).

"I would have preferred to see exams that were more population-based (for the lack of a better term) in terms of techniques, knowledge, critical thinking skills, etc. For example, oncology massage requires more than what people get in massage school.  Injury rehab and management requires more than what people get in massage school.  Same with pregnancy massage.  If I understand the new exam correctly, and Whitney (Lowe, LMT) can correct me if I'm wrong, this is a generalized advanced certification (and I don't know what that means).

"Also the survey that goes out for the job task analysis will probably go to therapists who primarily graduated from 500 hour schools. How does that say what is needed for an advanced certification?  I'm simplifying here, because others will no doubt complete the survey too, but you get the idea.

"I think they jumped into this without doing enough of the foundational work, but I could be wrong about that too."

Lowe: Chose to withdraw from NCBTMB team

Schwartz' colleague, author-educator Whitney Lowe, LMT, sent this additional e-note:

"I would concur with everything Jan has said here. I was on the task force that was working on this exam for a short time, but I resigned in protest due to the way in which I felt they were rushing the exam development process and not addressing key psychometric issues.

"The problem stems from an attempt to address a key need in our field (the ability to distinguish a massage therapist with basic knowledge from one with more advanced skills).

"[The offering] is also influenced by the NCBTMB's need for this exam to generate significant revenue because they are  losing their primary revenue stream with their existing entry-level credential."

"However, it is also unfortunately influenced by the NCBTMB's need for this exam to generate significant revenue because they are losing their primary revenue stream with their existing entry-level credential. This has led to a number of serious errors (which Jan has mentioned) in the exam development process and subsequently this also threatens the validity of the exam. (Another issue is that many in our profession don't understand basic principles of psychometric validity so they don't see the disconnect behind these concerns.)"

The loss of income to which Lowe refers is that a new Federation of State Massage Therapy Boards was created recently and offers an exam that is increasingly supplanting NCBTMB's certification as a route to licensing. 

Oz: Part of Sharecare content group

American Chiropractic Association partners with Mehmet Oz, MD, others in Sharecare.com

"From ACA to the American Red Cross, the American Diabetes Association, John's Hopkins Medicine, and others, Sharecare is bringing together the top minds in health care to provide consumers with multiple perspectives within a single Web site dedicated to improving health. The site will arm patients with more information about their health care options and empower them to make better choices."

Comment: Sharecare is an "internet play" with a world-wide vision and mission and with apparently some significant financial backing. Howes, for instance, is a former deputy director of a Bill and Melida gates Foundation unit involved with global health campaigns. In the business press Arnold is described as "the latest  entrepreneur to test the potential of social networking." AOL founder Steve Case's Revolution Health is noted as a recent expensive failure. This is one to watch. The ACA has little risk.

Redwood: Looking at core principles

Redwood's piece focuses on "putting the integrity into integration"

In a commentary in the premier issue of the peer-reviewed Focus on Integrative Health Care, educator and writer Daniel Redwood, DC, lays out a case for his belief that "sustainable integrative health care systems must identify and nurture beliefs and behaviors that model health-affirming ideals, including patient-centeredness, openness, pluralism, holism, preventive self-care, harmony of action and belief, and minimalism." Redwood's piece is called Walking Our Talk: Putting the Integrity into Integration. Redwood's perspective draws from principles for integrative medicine lined out by Centers for Medicare and Medicaid Services administrator Donald Berwick, MD. He also highlights the "4 Pillars (Integrative collaborative care; Cultural competence; Clinical sensitivity; Technological innovation) and 2 Guideposts (Increased services to the underserved; Decrease the brain drain of healthcare professionals)" offered by integrative medicine clinician, policy activist and educator Len Wisneski, MD. Also cited by Redwood are some principles for health care renewal developed in 2001 and cited in the report of the White House Commission on CAM Policy.

Comment: Taking principles for granted is a dangerous business. Principles need tending, particularly if such tender shoots are to survive in the getting-and-spending, rough-and-tumble of capitalistic health care in the United States. My close colleague Pamela Snider, ND calls this tending "operationalizing the soul" of one's medicine/health care. Good for Redwood to focus in on this intersection of principles and for Focus editor Cheryl Hawk, DC, PhD to highlight this topic in the journal's premier edition.

Expands integrative medicine-oriented site

40-million plus Huffington Post expands its integrative health space

The immensely successful liberal-left Huffington Post has chosen to give more presence to its medicine and health content by moving it out of the "Living" section into its own space. The content is overseen by a Medical Review Board replete with integrative medicine leaders. Dean Ornish, MD serves as medical editor and homeopath, acupuncturist and nutritionist Patricia Fitzgerald, DHM, LAc, CCN serves as "wellness editor." HuffPo boast over 40-million unique visitors per month. The site's editorial line promotes integrative medicine.

Side-note: Ornish's bio states that he holds the Safeway Chair at Preventive Medicine Research Institute. Safeway has been a leader in corporate wellness modeling. Ornish and Safeway struck up a multifaceted relationship in 2005. (Thanks to Integrator adviser Jan Schwartz, MA for tipping me to the HuffPo story.) 

Study increases awareness that sometimes a placebo is not

LA Times covers research on active nature of placebos

A recent study in the Annals of Internal Medicine is leading some to question the findings of a large body of scientific literature. The reason is captured in the title of a related Los Angeles Times article: A placebo is a placebo is a placebo .. or maybe not, a new study suggests. Noted as an example is the use of a lactose pill as a placebo in a large trial which, due to the lactose intolerance in many people, is not inert. Thus, by potentially worsening the symportoms of those on "placebo," to tested agent could be read as more positive than it is. The conclusions may have over-stated the drug's value compared to what was clearly an uncontrolled control. The original Annals article is entitled What's in Placebos? Who knows? Analysis of Randomized-Controlled Trials. The authors discovered that only 8% of studies with pills disclosed the nature of placebos (26% for injections). They recommended a policy of full disclosure.

Comment: The issue is of particular interest to the integrative practice fields given that not at all inert "placebos" have been used as "sham" acupuncture and manipulation - with outcomes that too often hit the media as "no better than placebo" when both treatment and placebo may be better than customary care.      

People

Michael Cohen, JD, MA

Integrative attorney Michael Cohen joins California law firm

Integrative care author and attorney Michael Cohen has joined the Fenton Nelson healthcare law practice in Los Angeles. Cohen writes that he has "joined a stellar Los Angeles-based healthcare firm and am continuing to represent CAM providers and entities within a sophisticated, national health law practice." Cohen, formerly part of the integrative medicine team at Harvard University, and most recently located in the Bahamas, has written over 100 books and papers on the maturing field. He continues to author the CAMLawBlog. A review of Cohen's Healing at the Borderland of Science and Religion is here in the Integrator. 

Charles DuBois

Standard Process president Charles DuBois honored by Foundation for Chiropractic Progress

Charles C. DuBois, president of Standard Process Inc., was honored with an award from the Foundation for Chiropractic Progress for his dedication to chiropractic profession. Kent S. Greenawalt, chairman and founder of the Foundation stated: "Charlie and Standard Process are truly dedicated to helping the Foundation generate positive press for the chiropractic profession."

Chris Ellis

Chris Ellis takes over as executive director of the AAAOM; Christensen thanked

Management consultant Chris Ellis has taken over as executive director of the American Association for Acupuncture and Oriental Medicine (AAAOM). According to a notice from AAOM, Ellis "

Lori Knutson, RN, BS-HN

Knutson in new role as Allina Hospitals & Clinics expands integrative healthcare

"officially transitioned my role to lead the Allina-wide Integrative Health Clinical Service Line as we are officially moving this work across Allina." The move is significant as Allina has 12 hospitals in its system, plus an array of clinics and other facilities. Adds Knutson: "We open our comprehensive integrative oncology center in November and I am now working on a Whole Family Integrative Health Clinic in partnership with Minnesota Children's Hospitals & Clinics IM group" led by Timothy Culbert, MD.

Shelly Johnson

Shelly Johnson appointed the new interim executive for the American Massage Therapy Association