Can alternative medicine lower costs?
Law institute says it’s time to make an evidence-based case for covering alternative therapies.
From the pages of In Business magazine.
Has the time finally come to pay complementary and alternative medicine the ultimate compliment and provide wider insurance coverage for them? It is, say advocates of so-called CAM therapies, but not without evidence-based research into their safety and effectiveness.
While these therapies already are used by a growing number of Americans, there is limited scientific evidence to support their efficacy. By not studying these often more affordable treatments, some believe we are missing opportunities to bend down the medical cost curve. The cost of health care still is rising much faster than the rate of inflation and the curve is still bending the other way, consuming 17.5% of gross domestic product, according to the Centers for Medicare and Medicaid Services. Through 2025, health spending is projected to grow 1.3 percentage points per year faster than GDP, bringing health care’s share of our national wealth to 20.1%. Nobody believes this trend is sustainable.
From the Chicago area comes a call to invest more for studies that could provide the evidence-based research necessary for health insurers to offer fuller coverage of chiropractic, acupuncture, massage therapy, and other varieties of alternative medicine. The DePaul Journal of Health Care Law, which is part of the Mary and Michael Jaharis Health Law Institute at DePaul University, has proposed statutory reforms to the Affordable Care Act to encourage CAM research and development and greater use and coverage of “demonstrably effective CAM treatments.”
The Journal says the ACA should require health insurance plans to reimburse for evidence-based CAM and grant authority to empower the National Center for Complementary and Integrative Health to regulate CAM standards and to recommend evidence-based services.
The Journal also contends that a hybrid system of limited intellectual property protection and government prizes based on regulatory approval “may be the best option for incentivizing R&D on CAM,” along with increased funding for research through the National Institutes of Health. Together “these policy and funding mechanisms should help reduce U.S. health care costs and improve quality of life,” the Journal asserts.
While there is some medical insurance coverage for CAM therapies, more evidence is needed to convince insurers to expand coverage, says Katherine Schostok, executive director of the institute. “There is definitely a push to do more studies to look at these alternative kinds of medicines, but right now it’s pretty limited,” she notes.
The institute’s push is explained in a paper that acknowledges the Affordable Care Act focuses on preventive medicine and wellness-based treatments, but added that it does not adequately take into account the potential contribution of complementary and alternative medicine.
Michael Johnson, coordinator of integrative medicine services for UW Health and a certified massage therapist, notes that Great Britain has universal health care. Under the British model, the National Institute for Healthcare Excellence oversees all protocols for standards of care. This government committee establishes evidence-based guidelines for common medical complaints, but one of the most challenging common conditions to deal with at the primary care level is low-back pain.
The typical approach is medication to manage pain, as well as physical therapy. “If that doesn’t work, they move to injections and images pretty quickly,” Johnson notes. “Those injections and MRIs are pretty expensive, and they don’t always help.”
Katherine Schostok (center) meets with staffers at the DePaul University Health Law Institute. The institute’s Journal of Health Care Law has called on the federal government to invest more in studies that could prove the efficacy of so-called complementary and alternative medical therapies.
A few years ago, the committee came up with the protocol for low-back pain at the primary care level and concluded, in the initial medical response, there is enough evidence to show massage therapy, acupuncture, and physical therapy or some sort of movement-based exercise routine should be the standard of care. “You’re not allowed to do any injections or MRIs for the first year,” Johnson adds.
UW Health, an integrated health system of the University of Wisconsin–Madison, considered whether to establish a similar model here. According to Johnson, a pilot program had been discussed for one of the system’s primary care clinics in which half the patients with low-back pain would be treated with the British protocol and half would be treated with a more standard model. The results were to be tracked in terms of cost and patient satisfaction. “At the time of the proposal, funding was not available to support the use of services which are not covered by insurance, so the proposal did not proceed,” Johnson explains.
In Johnson’s view, health care organizations are in a Catch-22 where insurance companies don’t want to cover the services due to the lack of cost-benefit data to demonstrate cost savings. Such research is badly needed, and yet it’s very challenging and expensive to conduct those studies. “Evidence is building for the effectiveness of integrative medicine therapies, but insurance companies need to be assured that covering these therapies will be cost effective in addition to improving patient care,” he notes.
The challenge for integrative medicine is that a number of its services don’t lend themselves to controlled clinical trials. There is an existing standard in traditional medicine that insurance companies want to see, and given the individually tailored treatments of nontraditional therapies, practitioners can’t standardize protocols and track patients. “Although it is a big Catch-22,” Johnson says, “things are changing slowly and we believe that integrative medicine therapies will be covered more and more in the near future.”
Even if Congress were to provide funding for CAM studies, such studies have inherent difficulties, Schostok acknowledges. “When you’re dealing with something that’s not streamlined, the etiology [study of causation] of pain or the etiology of symptoms can sometimes be called into question,” she notes. “When you’re dealing with chiropractic medicine or you’re dealing with different types of acupuncture, whatever it might be, sometimes people are seeking out treatment and they don’t actually know the cause of what they are experiencing.”
Without a full diagnosis, which sometimes is the case with alternative medicines, it’s hard to accurately examine the effectiveness of an alternative treatment. It’s also difficult to get participation from people for such studies, and it’s hard to evaluate the quality of practitioners for some of the newer forms of CAM. That said, Schostok believes CAM therapies can be accurately studied. “The way to accommodate these factors is to make sure to have a diagnosis before you evaluate people,” she states. “If you are going to do a longitudinal study to look at the effectiveness of these treatments, if you’re going to study for a year or two, it would be really helpful to control for the people who don’t have a diagnosis in the more traditional setting.”
Having a diagnosis on record is becoming less of a hurdle because now practitioners in more traditional settings are starting to recommend CAM treatments — to the point of making referrals — to their patients. Schostok believes the best areas to start are disability cases and conditions where traditional allopathic medicine has not been as helpful such as fibromyalgia, where acupuncture has shown the most promise in alleviating muscle pain, fatigue, and other symptoms.
“It also depends on how the pitch is made in the end, and if you tie it to something that’s a little bit more tangible,” she says. “Acupuncture and some less conservative treatment options have been very helpful to people who suffer from insomnia and in people who suffer from chronic headaches. That makes it a little bit more tangible for those in politics because it is something that they can relate to.”
The CAM advantage
Michael Ostrov, chief medical officer for WPS Health Insurance, is the former medical director at Group Health Cooperative-South Central Wisconsin, where he started a CAM program. Many people have asked Ostrov’s opinion as to whether CAM therapies can reduce medical costs, and he believes there are different ways to look at it. One is to look at the evidence for individual types of therapies and common ones that fall under CAM — acupuncture, massage therapy, cranial-sacral therapy, and Reiki.
Another is to ask whether therapy is the only consideration, especially because CAM practitioners often do more to engage patients in taking more direct responsibility for their own health. When Ostrov started the CAM program at GHC-SCW, doctors initially were skeptical because of thin evidence of its efficacy. However, once the organization had therapists on board, many people who had all the usual medical procedures and still weren’t feeling well were referred to them.
“They would send these people to the therapists and have great results in the sense that the therapist took a very holistic view of people and said, ‘We’re not just going to give you a type of massage and expect that you’re going to feel better,’” Ostrov explains. “‘There are a number of things that you need to do to take responsibility for your health.’”
One of the limitations of a traditional medical practice is time. According to Ostrov, a busy physician might see more than 20 patients a day, whereas a therapist might see seven to 12 patients a day. A typical medical appointment is 15 minutes long, and that might be generous given other physician responsibilities such as tending to medical records and ordering prescriptions. In contrast, he says the typical amount of time patients spend with CAM practitioners is about an hour. “Some of that is the ability of CAM practitioners to devote more time to people and get people more engaged in taking self-care,” Ostrov notes.
Patricia Smith, an occupational therapist and lactation consultant with Nurturing Touch Therapy, says her cranial-sacral therapy services are sometimes indirectly covered as part of physical or occupational therapy that’s covered, or under an employer’s flex spending plan. Smith often comes recommended by primary care physicians, neurologists, and pediatric neurologists, especially if someone has post-concussion syndrome. Just about every person that seeks her services is willing to pay out of pocket before attempting to get reimbursed, in part because traditional medicine has not changed their circumstances.
“I do cranial-sacral every day and a lot of times that’s what people seek me out for. Because I’m in a private practice in Madison it’s really hard to get insurance coverage. Most people have one of the four HMOs in town and usually they only cover providers who work at their clinics. Private practitioners do not usually get a whole lot of insurance coverage in Madison.”
As for studying alternatives, she concedes the difficulties. “In more allopathic care, what often happens is there are specific protocols,” she explains. “If you have frozen shoulder, you do these three things. That may or not be helpful, but at least you know this is what we do for frozen shoulders. When you’re doing more nontraditional therapy, practitioners are more likely to be looking more individualistically, so it’s much harder to do an evidence-based study on this. That’s where some of the research gets a little more challenging.”
While insurance coverage for acupuncture is widely variable, Colleen Lewis, a certified acupuncturist with UW Health, sees hope in corporate wellness programs offering more CAM services to reduce their worker’s compensation costs. Employers are starting to offer it with treatments like massage therapy, and Lewis gets referrals from integrative care doctors and from doctors who had patients tell them they’ve had good luck with acupuncture.
When she first started full-time in 2004, Lewis thought there would be full coverage by the time she went into practice. “We are still nowhere near that, but I have noticed that back when I first started, when people would go in and ask their doctors about acupuncture, the doctors would say things like, ‘Well, we don’t know if it works or it can’t be proven that it works.’ Now when people go to the doctor and ask about acupuncture, the doctor will often say, ‘It’s worth trying and it’s not going to hurt you.’”
Lewis cited fibromyalgia as something acupuncture has shown some promise in treating better than traditional western medicine, which is limited by what blood tests and images show. “One of the reasons is that something like fibromyalgia, or chronic fatigue and irritable bowel syndrome, those are conditions that are hard for the western medical model to treat,” she states. “We don’t have to be limited by the western medical model to be able to treat those kinds of things.”
Lewis agrees that it’s difficult to research CAM treatments, but it’s doable. She cites the example of sham acupuncture, where the patient might still notice a change in a double-blind study in which neither participants nor researchers know when an experimental medication has been given. “They will have somebody with a toothpick touch somebody’s skin, and that mimics what a needle would feel like and they would see what happens. Often, and we don’t know if it’s a placebo effect or the fact the skin has been stimulated, the person will still have a change and it can’t be attributed to acupuncture because that’s not what it was.
“It’s really hard to study this kind of thing because you know if you have a substance like a pill, you can give somebody a sugar pill and the other guy gets the real pill. Then you can measure the difference if you have that kind of thing to test. With acupuncture, it’s just so much more subjective.”
Dr. Daniel Robb of Robb Chiropractic Clinic in Monona also says his medical discipline has gained more respect from practitioners of traditional medicine. Robb has physicians as patients and he refers patients to physicians, but he knows there’s always going to be some division among health care providers. “There are [even] divisions among chiropractors,” he notes.
Medicare, the federal government’s health insurance program for seniors, covers chiropractic, and by law Robb notes that insurance must cover chiropractic in Wisconsin. “If you had HMO insurance coverage, you would be given a list of chiropractors and you would have to see them within your policy,” he says. “Most people, like they do with their physician, have deductibles and copays, and that would apply to chiropractic.”
Robb doesn’t view chiropractic as an alternative medicine and says some patients come to him after not getting the care that’s appropriate for their condition, so they end up paying for his services out of pocket. “They would rather see me and pay cash out of their pocket than pay their $15 copay with someone within their plan,” he states.
However you define alternative medicine, CAM therapies have made their way into the mainstream with variations offered at Dean, GHC-SCW, and UW Health. “What people are finding is the patients are seeking it out because they find it’s helpful,” Smith notes. “That’s the key.”
Integrative body shop
Don’t call what Michael Johnson does complementary or alternative medicine. Johnson, coordinator of integrative medicine for UW Health, is a certified massage therapist and his job title offers a clue to the terminology he favors. Integrative medicine also is the term preferred by the organization because its services are integrated with traditional medicine.
“We see all kinds of patients and look at the bigger picture,” Johnson explains. “We look at the patient’s whole medical record and history but also all aspects of what’s going on in their lives, and then they try to give them information about things they might not be familiar with — things that traditional allopathic medicines might not be as familiar with — to supplement what they’re doing medically.”
Johnson says the term integrative medicine is not interchangeable with complementary and alternative medicine (CAM). When UW Health’s integrative medicine program was established, founders felt the term “complementary” suggested that services could not really stand on their own and “alternative” suggested they would never be part of mainstream medicine.
“Integrative is actually bringing these things in, and the term integrative medicine has been around for a while now and it’s starting to change again,” he says. “We’re contemplating whether we want to keep that name or do something different as we move forward.”
Johnson is both an athletic trainer and massage therapist, but acknowledges limited research into therapies outside the realm of traditional medicine. In terms of both safety and efficacy, he says there is more information available about acupuncture. “That has been growing for many years because it involves needles and there is a lot more scrutiny,” he states. “Massage therapy is pretty gentle and safe and noninvasive, so there hasn’t been as much focus on it.”
Medicine on pins and needles
To use a bad pun, it’s hard to pinpoint exactly how acupuncture works. Most people have a general idea that acupuncture is a method of relieving pain by placing pins into a person’s skin at certain points on the body, but much of the certainty stops there.
Colleen Lewis, a certified acupuncturist for UW Health, notes there are five different “western mechanisms” explaining how acupuncture works, but it boils down to bringing blood flow and lymphatic flow to the area acupuncturists are treating.
There are some systems where you don’t place needles anywhere near the trouble spot. “You put them somewhere else on the body,” Lewis explains. “Let’s say you have low-back pain. I might place pins in your arms to get rid of that low-back pain.”
How then is she bringing blood and lymphatic flow to that area? Some people think it’s working through the myofascial system because that encompasses all the muscles and tissues in the body. “What we know is that once you put these metal wires into the system, there is a reaction by the system,” Lewis says.
Low-back pain is only one condition acupuncture treats. Physicians refer patients to acupuncturists for osteoarthritis in the knee, and Lewis treats people with digestive issues, eating disorders, and diabetes. “Acupuncture is not a solution for all pain,” she notes. “Most acupuncturists tend to be better at some things than others, and there are even acupuncturists who specialize.”
Lewis does her best not to get on patient’s nerves. “I’m trying to avoid the nerves,” she states. “If I put a pin in and it’s really painful, I know I’ve hit the nerve. I’m trying to calm down the central nervous system.”
In Latin, the word chiropractic means practice with the hands. Most chiropractors do their spinal adjustments with their hands, while others use instruments to do adjusting.
Dr. Daniel Robb, who prefers a gentle approach to spinal manipulation, is one of these practitioners. At Robb Chiropractic Clinic in Monona, he treats everything from back pain to headaches, vertigo (balance issues), and sciatica (nerve pain).
Chiropractic was founded in Davenport, Iowa, the site of Palmer College of Chiropractic, in 1895. “We’re only 120 years old, this profession,” says Robb, “and we’re the largest health care profession in the world aside from traditional allopathic medicine.”
Each chiropractor develops a series of techniques taught at places such as Palmer. A number of the conditions they treat are muscular in nature, but what makes chiropractic unique is that spinal adjustments can impact the nervous system.
“The two control systems of the body are the nervous system and the hormonal system,” Robb explains. “They are the two regulating systems that help us feel really good or really bad. As a chiropractor, I feel we can make important life changes for our patients through the delivery of spinal adjustments.”
Robb realized chiropractic had earned wide public acceptance 10 years ago by an angry response to proposed budget cuts that would make access to chiropractic more difficult. Thousands of patients and many chiropractors gathered at the Capitol to express their disapproval, and lawmakers had never seen anything like it. These protestors were their constituents, and their actions had a profound impact. “They [lawmakers] said, ‘We got the message,’” Robb recalls, and the proposed changes were nixed.
The light touch of cranial-sacral therapy
Patricia Smith cites a moderate amount of evidence to demonstrate the efficacy of her specialty, cranial-sacral therapy, but like other CAM therapies most of the validation comes from patients who are willing to pay out of pocket.
Smith, an occupational therapist and lactation consultant with Nurturing Touch Therapy, provides a light-touch manual therapy that works with the system of the spinal fluid and the fascia (connective tissue) and muscular skeletal systems, as well. She applies about five grams of pressure, which is different from massage therapy in that instead of applying heavier pressure to the muscles, it works more with the fluid system to affect the muscles, the central-nervous system, and other parts of the body.
Patients are seeking such CAM therapies because they are finding them helpful, but in most cases insurance does not cover cranial-sacral therapy. “Cranial-sacral tends to help a lot with headaches and with cases of trauma from car accidents,” Smith explains, “so most people will come for a treatment and know they are going to be paying out of pocket and not get reimbursed.”
Smith typically charges per session and has variable rates depending on the length of the session and patient’s condition. She works with people of all ages, and as a lactation consultant about half of her practice is devoted to infants and children. Some insurance plans cover her lactation services.
According to Smith, the problem with developing evidence-based research on CAM therapies is they are not as protocolled. “What you’re doing is individualizing care for that person,” she explains. “I might treat your headache much differently than I would treat somebody else’s headache because you have different reasons why you have headaches.”
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