Discussion

Following the keynote presentation, several members of the audience offered their thoughts on how the current health reform discussion could be shaped to advance integrative medicine and improve the health of the nation.

Panel Introduction

Sean Tunis, Center for Medical Technology Policy

Panel moderator Tunis noted that his background is not in integrative medicine but that his past work as chief medical officer for Medicare and current work as head of the Center for Medical Technology Policy has made him a realist. He reiterated Harkin’s statement that just because health reform and its inclusion of integrative approaches make sense, does not mean it is inevitable—such significant changes will face formidable challenges.

Tunis said that summit participants should take the opportunity to become effective advocates, to engage in the debate, and to focus their energies on the most promising avenues for change. Many aspects of potential health reforms will affect the future of integrative health care. For example, reforms that tie reimbursement to outcomes will reflect not just how much practitioners do, but the extent to which their contribution actually improves patient outcomes. When financial incentives are set, someone, at some point, will define which patient outcomes matter. Tunis said that integrative health care practitioners will want to be part of that critical discussion. Generally, Tunis observed, integrative medicine has been absent during the push toward comparative effectiveness research, and advocates for integrative health care need to work to assure that integrative approaches receive adequate attention as this type of research moves forward.

Tunis noted that this panel was designed to explore the challenges and the solutions, mechanisms, strategies, and tactics that will help ensure that integrative health care becomes a key component of a newly reformed health system.

Economic Burden of Chronic Disease

Kenneth Thorpe, Emory University

Thorpe opened with an array of statistics that exemplify challenges in the current health reform debate. He noted that three-fourths of U.S. health care spending is for patients with one or more chronic conditions, which makes these disorders a prime target in efforts to improve the quality and affordability of care. Obesity rates in the United States have doubled since the mid-1980s; this increase alone accounts for about 30 percent of the subsequent growth in health care spending and costs about $220 billion a year. Further, for every dollar we spend on medical care costs linked to chronic illnesses, we lose another $4 in productivity. While heart disease caused the largest increase in Medicare costs between 1987 and 1997, it is no longer even in the top five cost contributors, which are: diabetes, asthma, pulmonary conditions, arthritis, and back problems—health problems, like heart disease, that can, in many cases, be linked to personal lifestyle.

Thorpe observed that, with this president and this session of Congress, there is a greater opportunity to put together a coordinated, administration-wide policy on prevention. Currently, numerous unconnected and uncoordinated programs operated by HHS and other federal agencies offer different ways to intervene to promote health and prevent disease. Organizing these programs in a coherent, thoughtful way could have a tremendous cumulative impact.

To improve health care outcomes and reduce costs for the large number of Americans with chronic conditions requires actions outside the traditional physician’s office. Thorpe noted that today’s patient populations and their clinical characteristics are very different than when Medicare was enacted, and many of the services patients need most are not necessarily services that must be provided by a physician. However, the reimbursement system is based on benefits designed four or five decades ago and does not accommodate these needs. Policy makers must figure out how to encourage and cover both nonphysician services and team-based care, said Thorpe.

Large systems, like the Mayo Clinic, Geisinger, and Kaiser Permanente have solved some of these problems. However, most Americans do not obtain their health care through sophisticated, integrated group practices. In fact, more than 80 percent of U.S. physicians practice in ones and twos, and these small practices account for about 40 percent of the nation’s primary care capacity. Thorpe said that strategies must be devised to transfer to the small-office setting some of the functionality and useful components that make those large models effective. Senator Baucus, for example, is focusing on delivery system innovations. One model under consideration is to assemble community health teams that include nurse practitioners, social workers, behavioral health workers, and nutritionists that can collaborate with an area’s small physician practices and provide care coordination, primary prevention, and community-based outreach services. Lessons can also be learned from innovative state- level approaches to reform such as those in Vermont, North Carolina, Rhode Island, and Pennsylvania. These models frequently factor in community-based prevention strategies and small physician practices.

Insurer Perspective

Reed V. Tuckson, UnitedHealth Group

Tuckson reminded summit participants that health insurance companies such as UnitedHealth Group have agendas and missions that are well aligned with the summit’s goals. Many insurance companies work hard to ensure responsible policies for prevention, wellness, and integrated care, he said. In fact, UnitedHealth Group views itself as “a health and well-being company”; for example, the company spends millions of dollars to collect and analyze data, in order to identify individuals’ risk factors for disease, then provide them with a variety of individually tailored support services to assist in personally appropriate preventive interventions. It also uses its data to identify gaps in care; conducts sophisticated analyses to assure that individuals have received appropriate care; provides evidence-based guidance to individuals through their preferred electronic or print vehicles; and facilitates access to health coaching from trained clinicians. Tuckson said that these are just some elements of the company’s patient-centered care capabilities that are devoted to enhancing health and wellness for each individual.

From an insurer’s perspective, one of the most significant barriers to expanding integrated health care is the unsustainable escalation in health care costs. One major contributor to that cost escalation, he said, is “Everyone wants everything all the time.” As more people experience preventable chronic illnesses, as increasingly expensive pharmaceuticals and technologies are developed, and as consumer demand remains insatiable, health care costs will continue to be challenging, according to Tuckson. Financing for new interventions and for services associated with integrative medicine will present new challenges, he said, especially until researchers produce convincing evidence of clinical and cost-effectiveness. Concerns about the quality of current clinical care delivery form an equally challenging context for the introduction of integrative medicine, said Tuckson. Research indicates that almost half of clinical care delivery today is inconsistent with prevailing evidence-based guidelines. In the case of new (often expensive) technologies, the criteria for clinical appropriateness are often weak, and deviation from the available evi dence is a frequent concern, noted Tuckson. Additionally, at an alarming rate, individuals fail to exercise personally appropriate health protecting and enhancing behavior; almost 21 percent of the population continues to smoke; the incidence of diabetes is increasing rapidly; and the prevalence of obese children is such that 32 percent of children and teens are overweight and 16 percent are obese.

Within this context, in order to gain acceptance for integrative health care, advocates must have a realistic organizing vision for what they are trying to achieve, how integrative services will be implemented, what the roles and scopes of practice are of key disciplines, and what the evaluation criteria are, said Tuckson. Decisions regarding the incorporation of proposed interventions must inevitably be grounded in evidence of effectiveness, and arguments about the difficulty of accumulating this evidence will not lessen the importance of this critical information. Advancing integrative health care will also require answers to a series of critical questions that Tuckson posed to the plenary session:

• Who pays for prevention? What are the relative roles of public, private, and individual resources?
• How can population-based prevention efforts be effectively coordinated with individual preventive initiatives? How can synergies be maximized?
• Should the staffing of new patient-centered multidisciplinary preventive care be static or fluid to meet case-by-case challenges?
• How are different members of the comprehensive care team trained, credentialed, evaluated, coordinated and reimbursed? What are ways to prevent redundancy and maximize efficiency?
• What is the health return for employers’ investments in integrative health care?

Finally, Tuckson said that the new integrative health team will require new coding systems in order to capture the services they deliver and new health information technology infrastructures that can record and enable assessment of their work on behalf of the unique needs of individuals.

Tuckson concluded his remarks by committing UnitedHealth Group to actively participate in the exploration of the questions noted above, particularly those related to acquiring the evidence necessary for advancing this important field.

Business Community Perspective

Thomas J. Donohue, U.S. Chamber of Commerce

The U.S. Chamber of Commerce represents three million companies, which gives the organization a strong interest in health care. The main health care concern for the business community today is that health care simply costs too much, especially for the growing number of retirees, said Donohue. Thorpe said that Medicare patients are different today than in the mid-1960s, and there are a lot more of them, said Donohue. When Medicare was enacted, actuaries estimated the average American’s lifespan at 62.5 years. Now, Americans who reach 65 live nearly two more decades, on average. This puts a tremendous strain on companies with growing numbers of retirees, and it creates serious dislocations in industries that employ far fewer people than they used to in order to accomplish the same—and more—work.

The fundamental change needed in this country, particularly for health care, is to stop blaming everyone else, said Donohue. The problems of our current system are not caused by health care providers or the insurance companies. “We are only willing to pay them so much, and as Reed indicated, we want every service available to man,” he said. To successfully move forward, everyone—corporations, hospitals, doctors, professional practitioners of every type, and insurance companies—must be involved in the reform debate.

The best strategy, he said, may be to identify and unite around common issues that everyone agrees to and can support. Wellness is one. Another is the need for serious health information technology, not only to find out which treatments work, what the best practices are, and where people get the best results, but also to run complex health care systems. Most important, he said, almost everyone can agree that there has to be a way to cover people who do not have health insurance, because care for uninsured people is being provided at an unnecessarily high cost.

Yet, there are issues where agreement will not come easily, including how to divide finite health care dollars. Donohue said that every advocacy group should understand that “You are a petitioner. You want your piece of the pie. The biggest thing we all have to worry about … is, how much pie is there? How much pie can we afford?” He cautioned that so ciety cannot bear the cost of a grossly expensive system created by petitioners, and that infighting cannot be allowed to negatively affect the issues having widespread support.

Donohue predicted that the business community will ultimately be supportive during the upcoming reform debates, because businesses are under severe pressure to change the status quo. In fact, he said, business can be a strong partner in reform efforts, building on the strengths of the employer-based health insurance system, which covers some 150 million Americans. Another strength offered by business is the investment many employers have made to develop a healthier workforce. They understand that healthier workers are more productive and reduce the employer’s short- and long-term medical costs. Donohue noted that the nation’s diverse workplaces are useful laboratories for experimentation with new models of care and are contained environments for measuring results.

Because of the employer-based system’s record of innovation, measurement capacity, and motivation to achieve many of the wellness objectives described at the summit, Donohue supports continuation of the employer-based insurance system over a single-payer model.

Employer Perspective

William W. George, Harvard Business School

George said “The employer-based system is the strongest part of our health care system,” and that integrative health care is the key to its future. In fact, George said that it will not be possible to offer health insurance to 100 percent of Americans unless we have a health system that promotes wellness and prevention.

George noted his belief that employers have a role and responsibility in health promotion and disease prevention. Employers—especially those in the health care field, which in many communities are the area’s largest employers—should serve as role models for customers and patients. Ways to do this include hospital food services that offer only healthy choices and no-smoking policies that cover a health facility’s entire property, including parking lots. The goal for employers that emphasize wellness is not achieving the lowest cost; it is to have 100 percent of employees fully present on the job every day—in other words, improved productivity.

Company CEOs need to take initiative and active leadership on health care matters and not delegate them to unions, health plans, or company benefits managers, said George. Instead, business leaders need to invest time on health care issues, make serious attempts to reduce paperwork that drives up costs, and recognize that employee health is tightly linked to company strategy and productivity goals. As an example, he said that Target stores find a direct correlation between the health of their employees and customer satisfaction. The stores where employees are healthiest have the highest customer satisfaction ratios, as well as the greatest revenue growth.

George also said that business leaders need to devise ways to engage employees in their health and empower them to take responsibility for it. The full range of wellness services that employees need starts with a corporate culture where health is something that is honored and enjoyed. This culture could include having nutritionists on staff whom employees can talk to as necessary; offering stress management options, support groups, and health coaches; and having a fitness center. These are not “perks,” he said—they are services that are important to health, and the workplace is one of the most convenient places to offer them. He also suggested that a great deal of support can be provided online with social networking, and that this support should be made fun.

Employees who are pregnant or have chronic conditions may require additional support and active management, some of which can be provided at work, said George. When employees need hospitalization, the employer should encourage treatment in designated centers of excellence, because of the direct correlation between volume and quality of care and, therefore, long-term costs.

Even with all these employer-provided options, the basic premise still must be that employees are responsible for their health. George said that the role of employers is to give employees the resources and, perhaps, even provide financial incentives for wellness. For example, employers could offer incentives for maintaining a healthy weight, healthy cholesterol levels, or practicing healthy behavior, like not smoking.

If employers took on these suggested roles, there would not need to be as many government health reforms, said George, although government should require portability of health plans, so that when people change jobs they can take their health plan with them if they choose. George supported pretax health insurance coverage for every American and development of private insurance pools for small groups of employees, employees without health coverage, and the unemployed, so that everyone can have access to health opportunities typically offered by large companies.

In conclusion, George also warned against blaming others, described by Donohue. Rather, he endorsed making integrated health care the core of our nation’s system and building on employer capacity, “so that wellness and prevention become the essential characteristic of every workplace in America.”

Behavior Change Incentives and Approaches

Janet R. Kahn, Integrated Healthcare Policy Consortium

Kahn began by building on prior discussions of summit speakers and participants, noting that a broad range of disciplines is involved in integrative care. For true integration, these diverse practitioners must be knowledgeable about and respectful of one another’s expertise and collaborate effectively in the interest of their patients, said Kahn. Integrative health care need not depend solely on doctors to do patient-oriented, mind–body care; rather, it should take full advantage of the existing experiential base of qualified providers.² This would allow patients real choice about the kind of provider they use. Moreover, making better use of the full range of providers who can serve in a primary care role—nurse practitioners, physician assistants, naturopathic physicians, and others—would help reduce the current primary care physician shortage.

In Vermont, for example, naturopathic physicians are now classified as primary care providers and are reimbursed by Medicaid, providing the opportunity for a natural experiment. In general, states’ authority to set scope-of-practice laws produces interstate differences in practice patterns, providing a valuable opportunity for comparative research on mechanisms for delivering primary care services.

At the federal level, Kahn said that a single entity should be responsible for coordinating integrative health-related policy efforts across agencies, perhaps through an Office of Integrative Health Care and Wellness. That office could be charged with scoring domestic policy proposals—not just those within HHS, but across the executive branch, including those related to education, transportation, the environment, housing, and agriculture—as to their potential impact on health and illness, just as the Congressional Budget Office scores the potential financial impact of all proposed legislation.

Kahn noted that social scientists have demonstrated that it is relatively easy to enhance someone’s knowledge about a behavioral health risk and slightly more challenging to help them shift their attitudes toward it, but that getting someone actually to change their behavior can be very difficult. Individuals have to decide not to smoke or not to eat junk food, not once or twice, but multiple times daily. There is no one best way to accomplish successful behavior change for everyone. Even with solid evidence of effectiveness for such interventions as smoking cessation, potential program sponsors need to know exactly how such programs should be implemented for their target population, and what their return on investment will be, said Kahn.

Clearly, health professionals do not change other people’s behavior—individuals must change their own behavior. However, health professionals can promote these changes with policies, incentives, and media messages that persuade people they want to change. While individuals do the hard work of changing what they eat and how they exercise, health professionals can provide emotional support for the individual trying to change, whether they achieve their goals or not. If they did not do it this time, they might the next.

Opportunities to facilitate behavior change are all around us. People are social beings embedded in networks—from preschools to workplaces to retirement homes—and health professionals should work in those networks to encourage behavior change. Also, people live in both natural and built environments that are dramatically different across the country and vary across class lines. These environments can be improved to make exercise easier or healthier food more available.

The workplace offers many possibilities for behavior change, including a wide range of incentives and rewards, such as those previously described. Incentives in the workplace do work and can offer an opportunity for cost containment. Kahn noted that some companies have been able to reduce their annual increase in health care costs to 1 percent, rather than the average 8 or 9 percent. But incentives can backfire, Kahn warned. Some employees may feel that these incentives, which require the regular collection of health information, impinge on their privacy. Workplaces that have been most successful have coupled financial incentives with team building and social support for behavioral change.

Central to success of behavior change strategies, whether across society or within a single workplace, is the use of multiple message channels and the alignment of these messages with policies. Kahn cited smoking cessation as an imperfect, but highly successful effort at health behavior change. In the United States in 1965, roughly 51 percent of men and 34 percent of women smoked. By 2005, rates of smoking dropped to 24 percent of men and 18 percent of women. Interventions that facilitated this change involved a coordinated health policy effort that included approaches ranging from increased taxes on cigarettes, to municipal regulation of where people could and could not smoke, to nicotine patches and workplace smoking cessation programs.³

Within a corporation or within a country, policy makers should not be talking about health and wellness on one hand while creating situations that lead to unhealthy behavior on the other, said Kahn. On the provider side, financial incentives encourage use of expensive interventions rather than prevention strategies. Incentives encourage medical students to pursue specialty rather than primary care careers. Equally powerful incentives for prevention and health should be purposefully reset, she said.

The goal, suggested Kahn, is to encourage people to want to change their behavior, and then to be prepared to help them when the point of wanting to change. This requires a state of readiness on the part of the employer, public health system, health care providers, and others, and this involves both removing barriers to change and having programs and systems that can provide necessary support. One aspect of this can be incentives that can make change worth it in multiple ways including financially and socially. To make healthy behavior normative, Kahn said, incentive structures must be aligned, not working at cross-purposes.

Rewards of Integrative Medicine

Kenneth R. Pelletier, University of Arizona School of Medicine and University of California (UCSF) School of Medicine

Analyzing the economics of integrative medicine defies easy economic analysis. When people approach such a difficult topic, they tend to turn to tools like cost–benefit analysis, with its aura of precision, said Pelletier. Cost–benefit analysis is a complex field with perhaps a dozen different alternative methods, all of which can provide useful information. These include cost–benefit analysis, cost-effectiveness analysis, assessment of net present value, return on investment, and econometric modeling, which can encompass all of the previous techniques.

Different cost–benefit methodologies reflect different perspectives. They often result in incomparable and even nongeneralizable outcomes. A systematic review conducted by Pelletier and colleagues provided several insights about these differences as they apply to integrative medicine (Pelletier et al., unpublished). Researchers examined all the definitions of the patient-centered medical home, chronic care management, extended primary care, and integrative medicine, and found that the various definitions have more in common than not. One of the distinguishing factors of integrative medicine was that, in the majority of definitions, it included evidence-based alternative medicine.

The researchers decided to examine what cost–benefit analysis would look like when applied to this distinguishing characteristic. They conducted an international literature search that yielded 59 cost–benefit analyses, 39 of which were considered full evaluations. From these, they identified eight alternative medicine modalities that appeared to be cost-effective in treating various conditions, including acupuncture, guided imagery, relaxation, and various forms of meditation. One specific cost-effective modality/condition pair was use of acupuncture for migraine. While integrative medicine is clearly not synonymous with complementary and alternative medicine (CAM), this research showed that there are CAM components that are likely to be cost-effective in an integrative care model.

Pelletier has dedicated time to managing clinical trials in various worksites, and he noted that corporations are perfect sites for implementing and evaluating integrative medicine. First, employers call people people not patients. He said that corporations have a vested interest in the health, performance, and well-being of their employees, while they have no vested interest in disease. Additionally, employers are not wedded to certain modalities of treatment, as long as it is effective in terms of clinical and cost outcomes. If, for example, an employer learns that acupuncture for back pain is superior to surgery, they would support the use of acupuncture.

Pelletier reported on research that identified 153 clinical and cost outcome studies of worksite integrative health approaches (Pelletier, in press), all of which have demonstrated net benefits in terms of short-term and long-term disability, absenteeism, general retention, key personnel retention, productivity, performance, and presenteeism.⁴ Of the 63 studies that used cost–benefit analyses, all but one older study showed positive results, and 24 reported a return on investment—the hard-to-reach measure that is the gold standard within the business community.

The most conservative return-on-investment result that would be considered positive is 1:1. Many people in a corporate environment would be very happy with a dollar-spent:dollar-value-recouped return, he said. But the returns on investment found in this literature ranged from 3.5–4.9:1. These are salient results, because the return on investment does not have to be very high for the dollar savings to be large. Pelletier also noted that, on average, rate of return outcomes were most evident after approximately 3.25 years, suggesting that these types of employer investments should be long term.

The potential for such persuasive results indicates that cost–benefit analyses should be included in assessments of integrative medicine programs, especially effectiveness trials. Pelletier predicted that integrative medicine and its preventive components will prove to be dramatically more cost-effective than many conventional services, at least on a purely empirical basis. He also agreed with Donohue and George that employers have a large stake in both ensuring employee health and involvement in health and medical care reform.

Pelletier said that within 2 to 3 years it should be possible to create a minimum set of standardized measures that could be used to assess any and all health services that purport to be safe, effective, and cost-beneficial. This would provide a basis for more accurate comparison of integrative and conventional care approaches. The problem in the nation’s medical care sector, which currently spends $2.5 trillion annually, is not that it needs more money. The problem is that these resources are misallocated, he said, because many of the services and interventions that are regularly paid for would not pass any of the measures of cost-effectiveness. By conducting appropriate cost–benefit analyses, Pelletier said it will be possible to create an evidence base for allocating health care resources in a more scientific and cost-effective way.

Panel Discussion

Members of the panel responded to questions from the audience in a discussion moderated by Tunis, who began the discussion by repeating what he called “a great truism about Washington,” which is that when everyone seems to agree on any policy idea, it usually means it has not been defined specifically enough. Tunis noted that the summit had engendered much agreement on what needs to be done to promote the adoption of integrative health care, and he encouraged participants to dive into some of the details.