Integrative Care

2011 word change may support whole person practices

"May" to "shall": 2011 revision of CPT a breakthrough for time-intensive, health-focused, integrative practices

"Effective January 1, 2011, the CPT manual has been revised to state that: 'When counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter, then time shall be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of counseling and/or coordination of care must be documented in the medical record.'"

"Until 2011, the bolded and italicized "shall" was "may." This change is of paramount importance to the naturopathic community because time spent with patients in counseling and/or coordination of care is that for which the profession has wanted to get reimbursed. This recognition of time throughout the healthcare system is a remarkable and important change! This change moves the United States towards a healthcare system which invests in wellness and health promotion. This one word change supports naturopathic physicians and other providers who "treat disease by restoring health" (AANP Definition of Naturopathic Medicine Position Paper 1989).

Milliman: Diligently pushing the CPT change

Comment: If one could put a paradigm shift in a nut-shell, this just might be the holder. The plaintive cry in human life that change takes time appears to finally be reflected in payment. Time is what it takes to work with patients toward better esteem, to movement up the gradients of readiness to action,

Comment: Step by step, better care options. This time the progress is, happily, baby steps.

Review shares 25 windows on cost-findings and business models in integrative practices in 2010

Comment: Cost is king in a capitalist economy. As I noted in my commentary on the mix of articles, the biggest question as the year draws to an end is whether costs will be elevated from its present invisibility in the draft NIH NCCAM 2011-2015 strategic plan's "strategic objectives" when the final plan is unveiled in February 2011. How else can NCCAM fulfill on the charge in Section C of the mandate to:

" ... study the integration of alternative treatment, diagnostic and prevention systems, modalities, and disciplines with the practice of conventional medicine as a complement to such medicine and into health care delivery systems in the United States."

Policy

Surgeon General Benjamin: Her draft short on integrative aspect of the law

Draft National Prevention Strategy nearly mum on "integrative care" despite significant inclusion in enabling law: Comments close 01/13/11

Comment: I mailed an "alert" to Integrator readers to stimulate response from the integrative practice community to the draft framework for the strategy (comment period closed December 5, 2010) and then the draft strategy itself (comments closing/closed January 13, 2011). The draft plan teases one with its language. The opening salvo is that the strategy:

" ... provides an unprecedented opportunity to shift the nation from a focus on sickness and disease to one based on wellness and prevention."

Senator Mikulski: Draft plan misses key elements in her legislation

Nice. Yet it seems to be doing so without embracing the challenges of bridging the chasm between reactive, sickness-focused clinical care and a wellness focus. This is precisely the promise that "integrative practice" represents. Wouldn't it be nice if clinical care was shifted to integrative, health-oriented principles and practices that create the kinds of prevention and wellness outcomes as side effects that were found in this report:

" ... (self reports) found improvement in multiple areas: fatigue, sleep, weight, stress, allergic symptoms, hypertension, coffee consumption and muscoloskeletal problems ..."

The so-far meager participation of the integrative practice community in this dialogue suggests that the community is not yet adept at either making its case or gathering the resources to show up. This is sad-making, particularly since the law gives "integrative care" significant standing. Hopefully, the community will increasingly seize opportunities as they arise.

Position on ACOs articulates concerns of other fields

Chiropractors organize strong response urging re-consideration of included provider types in Accountable Care Organizations (ACOs)

Comment:  The ACA's point is well made that those who may be responsible for savings should share in benefits. My guess is that the ACA speaks for more than one profession in calling for a "reconsideration of the practitioners that are needed in an ACO and to expand this list to include ... [your non-included profession here]." The ACA also spoke indirectly for other non-included or limited professions in its response to the NCQA:

"The limited nature of the practitioners who will be considered primary and specialty care practitioners in NCQA's definition of an ACO will seriously limit the ability to reduce per capita costs."

Note, for instance, the cost-savings in this report on the whole practice of naturopathic physicians. Given public use of chiropractors and other "CAM" practitioners, broad inclusion would also seem to be required if an entity is to meet the NCQA definition of an ACO as an organization in which "providers will need to be clinically integrated and work together to seamlessly coordinate care for assigned patients."

Academic Medicine & Education

Weil: Funds to open doors for 10 more MD/DO students

"LEAPS into IM" program for MD/DO students benefits from additional Weil Foundation grant

Medical and osteopathic students interested in participating in the Leadership and Education Program for Students in Integrative Medicine (LEAPs into IM) will benefit from roughly $20,000 in additional grant support from the Weil Foundation, according to a recent notice from the Consortium of Academic Health Centers for Integrative Medicine. The program, which grew out of an American Medical Student Association NIH-funded initiative, is presently led by Wendy Kohatsu, MD and Integrator adviser Bill Manahan, MD. Students pay $250 each for the week-long experiential, introductory program. The funds from the Weil Foundation, founded by Andrew Weil, MD, will allow the program to expand from 20 students to 30 students. Weil, contacted by the Integrator, offered this comment on the grant:

"This seems like a logical step for the Foundation.  We like to target our grants, to get maximum bang for the buck, and training medical students in IM is a great investment in the future of medicine."

Comment: I recently attended a memorial service for an early educator-developer of the AMSA program, Pali Delevitt, at which I was reminded repeatedly, via open sharing from beneficiaries, of how utterly life-changing these short programs can be for medical students who are in search of something else in their medical training. Good for the Weil Foundation to open the doors for another 10 students to participate. It's a pleasure to think of the nascent care-givers and leaders who will walk through this year.

Simkin: Bastyr childbirth education enter in her name

Bastyr University' Simkin Center trains doulas and allied birth providers

A November 30, 2010 newsletter from Bastyr University focuses on the University's

Comment: The integrative practice movement is inextricably connected to the natural childbirth and homebirth movement. My view comes to me in part through the immense experience of the home births of our two children. I may also be influenced to write this story as my spouse Jeana and I had the opportunity to take birthing classes with Penny. Great to see Bastyr housing these programs and affirming this connection between natural childbirth and our broader mission. This comes at time when doulas are organizing as a profession for 3rd party payment.

Mr. & Mrs. Bernard Osher: Substantial gifts to UCSF initiative

UCSF Osher Center moves into large new facility

Margaret Chesney, PhD, shares that the Osher Center for Integrative Medicine program at UCSF

Comment: Even close observers of developments in this field often miss that, inside of conventional academic medicine, we see layers and depths of integration. Often so-called "integrative medicine programs" start as satellite, arms-length or even quarantined initiatives. Chesney rightly is excited about this important step in actual integration inside of the medical center. Kudos, of course, to the Oshers.

Seitz: CNME hits key threshold for NDs

Naturopathic accrediting agency gets 5 year approval

Comment: The latest renewal of recognition is newsworthy given the wild ride for the CNME with the US Department of Education since the agency was first recognized by the USDE in 1987 when there were just 2 CNME-recognized on several occasions since. The first was for trumped up and ultimately bogus charges from mail-order NDs with what Seitz calls "online or abbreviated training" that don't meet the CNME standards. In one other instance, internal issues with CNME resulted in a hiatus in the agency's recognition. Happily for the NDs, and for quality, doctoral-level natural health education, the engine of opposition to the CNME, the former for-profit mail order business known as the Clayton College of Natural Health, shut its doors in 2010. (See HuffPo piece here and Integrator short here.) Twenty-three years later, there are now 7 CNME-recognized programs in North America. The latest review marks a new level of security for the naturopathic profession whose credibility is very much dependent on CNME's status with the USDE. Now to insure there is work for all those educationally-mortgaged graduates!

ALLEGRA Learning Solutions gains traction with AHNA for integrative health CE courses
 
A note from reader

2 of the firm's 10 certificate programs are "nationally accredited for continuing nursing education and they have just been nationally endorsed by the American Holistic Nurses Association." One is a new Certificate in Integrative Health, advertised as including "holistic stress management, humor, energy healing, meditation, spirituality, Traditional Chinese Medicine, Ayurvedic Medicine, bodywork healing therapies, healing environments, music and sound healing, nutrition, and the healing effects of physical activity and movement. (67 hours; $469) The second program, which was recently endorsed by the AHNA for the 2nd time, is a Certificate in Spirituality, Health, and Healing. (25 hours; $180) Allegra has 8 other programs, including one in Complementary and Alternative Medicine (28 credit hours; $196).

Ho: Drumming program has prevention, health promotion characteristics

UCLArts & Healing in Time Magazine article
 
"How Group Drumming May Improve Low Income Student Behavior" is the title of a December 9, 2010 article in Time magazine. The article focuses on a drumming-based behavior program for at-risk youth developed by Ping Ho, MPH, director of UCLArts & Healing. The projects was engaged in collaboration with the National Association of Music Merchants and drum-maker Remo Belli. The team offered and studied a 12 week, post-lunchtime, 45 minute, counselor-led drumming experience that created an array of positive outcomes in the group of 101 "mostly Latino" children. An analysis of the program found that "across all types of problems, each drumming lesson was associated with significantly more improvement than a control lesson." Said Ho: "We would have been happy with one [positive] outcome, so when the statistician kept reporting 'withdrawal improved' and then 'depression improved' and so on, it validated everything we believed," Ho says.

Comment: Interesting to note the parallel health-creating outcomes in this program as those noted above in the piece on the National Prevention Strategy and found in this report of integrative medicine practices. Unfortunately, these kinds of progressive programs Ho is creating appear to be as little part of the thinking in the draft National Prevention Strategy as are whole person integrative clinical practices. What a great, healing tool such a program may be for our schools and at risk kids.

Natural Products

Supplement leaders forge tie with nursing leaders

Council for Responsible Nutrition in joint education/promotion effort with nurse practitioners

On December 20, 2010, the Council for Responsible Nutrition (CRN) announced that it is working on a "joint education effort" with the American Academy of Nurse Practitioners and the American Academy of Nurse Practitioners Foundation (AANPF) "to help raise the level of awareness within the supplement industry and with consumers about the valuable role of nurse practitioners in the quest for good health." The release notes evidence from a survey that nurse practitioners both use and recommend supplements." Said

Nurse leaders form tie with supplement leaders

Comment: Here is the integrative medicine trivia question of the day: What do the nation's most powerful supplement industry group (CRN) and most significant health-care related foundation (Robert Wood Johnson Foundation) have in common? Answer: Both are actively promoting a growing role for nurse practitioners in US health care. (See #3 here regarding RWJF and NPs.) Fascinating, and smart, strategic move for CRN, to find in this rising set of primary care practitioners a more friendly partner, then pursue the partnership. It fits one of my favorite rules: Life is short. Play with those who want to play with you. The nurse practitioners are likely to be both more welcoming and a better use of energy and resources than concocting something similar with, say, the AMA.  

Report stirs controversy

Controversy stirred by Institute of Medicine recommendations on Vitamin D

The recommendations in the Institute of Medicine report on Vitamin D stirred an outcry from many nutritional medicine interests. Natural Medicine Journal seized the moment and published responses from researcher Alexander Schauss, PhD; from New York University's Geovanni Espinosa, ND; and osteopathic clinician Susan Ryan, DO. Ryan decries the way "the media further confounds" the recommendations. Eric Goldman, editor of Holistic Primary Care, explores apparent conflicts of interests on the IOM panel in Who's in Bed with the IOM: Vitamin D Report Supports Conflict on Interest Suspicion. One member has an interest in a synthetic Vitamin D product, for instance.

Quections conflicts, blasts methods, calls on Congress

Goldman credits the Alliance for Natural Health USA (ANH) for raising the conflicts issue. ANH upped the ante by promoting a letter-writing campaign to Ask Congress to Investigate the Vitamin D Report. One key issue, according to ANH, was the IOM decision to only focus on evidence from randomized controlled trials. The title of an ANH November 30, 2010 blog post positions the report as " ... Wrong, Wrong Wrong." The Council for Responsible Nutrition published a "reaction" to the report in which it argues that the IOM's recommendation of increased daily recommended intake is a "step in the right direction [but] still falls far short." While the IOM doesn't recommend higher than 800 IU's a day, and finds evidence of safety at only 2,000-4,000 IUs, CRN states that its affiliated scientists "have demonstrated the science would allow for raising the UL for vitamin D to 10,000 IU/day."

Comment: Fearing that anything I might add would only be more of the "media further confounding" the subject, as decried by Ryan, I turned to integrative nutritional pioneer pioneer Alan Gaby, MD, who I recently interviewed here on the publication of his 1374 page Nutritional Medicine textbook. I asked Gaby for a sentence or two. He wrote:

"While the IOM has often been excessively conservative, their recommendations regarding vitamin D appear to be reasonable. The evidence supporting the necessity and the safety of high-dose vitamin D for the general population (i.e., more than 2,000 IU per day indefinitely) is weak."

Organizations

Karan: Urban Zen program offers prevention, health promotion strategies

Donna Karan's Urban Zen partnerships for 2011

The new year's notice on January 3, 2011 from Donna Karan, founder of Urban Zen, found plenty to trumpet. Via a partnership with the David Lynch Foundation, the

Comment: I hope Ms. Karan and her team weigh in with the new National Prevention Strategy on some of these programs, particularly the 3 for school age kids. They might be interested in the UCLArts and Healing drumming program, too! Quite an agenda!

Comment: I asked Rowe for perspective on why this event took place. I didn't hear back at the time of publishing this. The only thing I could make out is that the  homeopathic presence among the money lenders had no direct relationship to Wall Street bonuses, which were quite comfortably in their whole form, though even at the worst of the economy never did appear as infinitesimal doses.

The pleasure of Top 10 lists indulged

A few Top 10 Lists from 2010: Integrator, AANMC, Community Acupuncture, plus ...?

Each year since 2006 the Integrator Blog News & Reports has published a Top 10 list of events and action from the  prior year. The 2010 list is here. In 2009 I added a Top 10 People in Integrative Practice. The 2010 "people" list is here. (Most of you won't be surprised that the people list has has more readers than the events list. Shows that at this level we are all well integrated with our culture.) Meantime, reader Lisa Rohleder, LAc, co-founder of the Community Acupuncture Network (on the 2006 list), sent a note on December 28th that she "took a lesson from you and started an end of year summary for the [Community Acupuncture Network]. Rohleder's posting is here. In addition, I also discovered while googling around regarding Huffington Post and integrative medicine (my #8 for 2010) that Coquina Deger of the Association of Accredited Naturopathic Medical Colleges, who also honored Arianna Huffington, is about to publish a Milestones 2010. Any other end of year lists from these fields out there?

Ernst: The gift of polarization

Bottom Feeder of the Year: Edzard Ernst for his pro-active polarizing

Comment: In the midst of the year end reflection, Italian integrative medicine leader Paolo Roberti di Sarsina, MD forwarded notice of an article entitled "Edzard Ernest holds forth again."  Apparently Ernst, a well-known CAM writer and a conservative conventional mouthpiece of late in England, published an article entitled "Acupuncture - a treatment to die for?" In a review of 20 years of acupuncture publications, Ernst found 469 adverse events (including, reportedly, "fainting"). That's 22 a year. A critical reader finds "the data are partial and his conclusions limited." Chiropractors will know that the same Edzard Ernst also published Deaths After Chiropractic in 2010, another literature review, another inflammatory title. Family physicians loved this study. Integrator reader and sometimes contributor Tom Ballard, RN, ND, sent notice that Medscape listed Ernst's work as the publication 4th most widely read among family physicians, spiking more poison into a bettering relationship historically filled with animosity. Long-time chiropractic researcher Anthony Rosner, PhD, in "another misbegotten review," offers evidence that Ernst work

People

Roberts: Next president for holistic doctor group

Molly Roberts, MD chosen as president-elect of AHMA

Clinician and author Molly Roberts, MD, MS has been selected as the president-elect of the American Holistic Medical Association. She will begin her term in November 2011. Roberts is an integrative holistic physician with

Integrative Pediatrician Kemper: ADD book published

Mind-Body Researcher Elizabeth "Lisa" Kimbrough Pradhan, MPH, PhD (-2011)

UCSF Osher Center director Margaret Chesney, PhD writes with news that

"Lisa dedicated her career with us to investigating Mindfulness-based Stress Reductions (MBSR), meditation, and traditional Chinese medicine.  A gifted researcher and writer, she authored or co-authored over 75 publications beginning in 1991 and was on the review board of five peer-reviewed journals in 2008-2009.  Lisa also won many well-deserved awards and honors during her career, such as the Francisco J. Varela Memorial Grant Award from the Mind and Life Institute and the George Family Foundation New Researcher Award.  Lisa balanced a rich career with her family life, including her 2 lovely children, Asha and Rajen, her husband, Ravi, and a large circle of friends who span the globe ... A devotee of healthy habits, Lisa could often be found running through a nearby park, skiing down a mountain, or deep in restorative meditation.  Above all, Lisa brought to everything she did compassion, caring, and a great sense of humor.  I will always treasure the memory of our morning chats that ranged from debriefing on the weekend's Ravens game, laughing about the politicians we wished weren't in office, to checking in on the research studies she ran with such ease and competence.  Lisa will be sorely missed, but her work will go on unceasingly, as she would want it to."