The daunting challenge - Complementary and Alternative Medicine

There is no question that the past few years have seen a tremendous surge in interest in what has come to be known as complementary and alternative medicine (CAM). Health plans contemplating adding CAM benefits face a daunting challenge. How should a plan define CAM benefits? How should a plan define appropriate CAM providers? How can these benefits be managed? Will the addition of CAM benefits undermine coverage policies for conventional biomedicine? The answer to these questions lies largely in uncharted waters, as even CAM advocates will agree that many alternative therapies (even those like Oriental medicine which has been in practice for some 5,000 years) have not yet undergone the type of rigorous, evidence-based analysis that is required to validate conventional biomedicine. This article explores options for CAM benefit design by considering two basic approaches-creating an uninsured benefit or insured benefit.

Key Concepts: Complementary and Alternative Medicine (CAM)/CAM Benefit Design/Insured Benefits/Uninsured Benefits

THERE IS NO QUESTION THAT THE PAST FEW YEARS have seen a tremendous surge in interest in what has come to be known as complementary and alternative medicine, or CAM. This growing interest may be related to dissatisfaction with conventional western medicine (also known as biomedicine) which is perceived as high-cost technology driven, associated with significant morbidity, and focused on the disease rather than the whole patient. In contrast, CAM is perceived as low cost, encompassing a more holistic approach to both health and disease, and significantly safer than biomedicine. Clearly, CAM enjoys an under-appreciated popularity In this country.

Two events in focused the attention of the biomedical community on CAM. The National Institutes of Health established the Office of Alternative Medicine (OAM) in 1992 to identify and evaluate CAM therapies. In addition, the OAM supports and conducts research and research training on CAM practices and disseminates information. In 1993, David Eisenberg and his colleagues published an article in the New England Jo urnal of Medicine which estimated that Americans made 425 million annual visits to CAM providers, the majority paid for out of pocket.' Eisenberg reported that annual CAM visits exceeded those made to primary care physicians. These seminal events served to raise awareness of alternative medicine approaches by bringing CAM to the forefront of the medical community and providing formal recognition of Its potential health benefits.

Attention was further focused on CAM providers with the 1995 passage of a Washington state law requiring health insurance plans to provide access to alternative health care providers (chiropractors, acupuncturists, and naturopaths) to treat conditions that would be otherwise covered under their health plan. Finally, some health plans began introducing limited CAM benefits in some of their products. The combination of all these events has created competitive market pressure and raised member and policyholder expectations that CAM benefits should be included as part of a health plan. In addition to market pressures, the cost-saving potential of CAM therapies has sparked additional interest among health plans.

Health plans contemplating adding CAM benefits face a daunting challenge. How should a plan define CAM benefits? How should a plan define appropriate CAM providers? How can these benefits be managed? Will the addition of CAM benefits undermine coverage policies for conventional biomedicine? The answer to these questions lies largely in uncharted waters, as even CAM advocates will agree that many alternative therapies (even those like Oriental medicine which has been in practice for some 5,000 years) have not yet undergone the type of rigorous, evidence-based analysis that is required to validate conventional biomedicine.

Definition of CAM

The definition of CAM itself is an interesting discussion. The OAM offers the following:

"CAM is a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well-being. Boundaries with CAM and between the CAM domain are not always sharp or fixed. " (2)

This relational definition suggests that one culture's CAM could be another's "politically dominant health care system." Therefore, using this definition requires also defining our politically dominant health care system; by exclusion CAM represents everything else. The NIH panel on Definition and Description of CAM suggests that "politically dominant" reflects broad acceptance as evidenced by "...medical practice laws, legally recognized accreditation and rights of self regulation, third-party payment, privileged access to public research moneys and to prestigious publication venues, high status, and so forth." (3)

Thus, current reimbursement policies by payers can be used to define CAM therapies. Health plans may find themselves in the contradictory position of considering offering benefits to therapies that by definition would be considered as ineligible for coverage due to their investigational or experimental status.

Although this broad definition might include therapies which had sought but failed to achieve validation through conventional biomedicine (e.g., unconventional cancer therapies), plans considering CAM benefits have typically focused on provider types, such as acupuncturists, massage therapists, naturopaths, and nutritionists, rather than on the health care system these providers represent, such as Oriental medicine, homeopathy, or Ayurvedic medicine. Many patients may undergo acupuncture or massage therapy, for example, without committing to the underlying philosophy of Oriental medicine.

Still, focusing on provider types creates additional dilemmas for health plans. For example, massage therapists can practice a broad array of techniques, ranging from the familiar

Swedish massage involving manipulation of soft tissues, to craniosacral therapy which involves gentle massage and pressure on the skull to restore the natural rhythm and flow of cerebrospinal fluid. How can health plans identify quality CAM providers for their networks? What type of massage therapy should be included?

State licensure is a good place to start, but some states do not require licensure for massage therapy. Certification by specialty societies can be another initial measure of professional qualifications, but for massage therapy, there are a variety of specialty societies representing subtypes of massage. However, of those states which license massage therapists, the majority have relied in part on certification from the National Certification Board for Therapeutic Massage and Bodywork which focuses on skills common to all massage therapy techniques. Some health plans may face a shortage of CAM providers in their markets, For example, there are only three licensed acupuncturists in Iowa compared to 3,600 in California; only 450 licensed massage therapists in Nebraska compared to almost 14,000 in Florida.

Options for benefit design

1. An uninsured benefit

Another fundamental decision facing health plans is the structure of the CAM benefit. Two basic approaches have been considered--creating an uninsured benefit or insured benefit. An uninsured CAM product refers to a structure in which the health plan assumes no or minimal risk in providing access to CAM benefits; for example, the member self-refers to a CAM provider and pays out-of-pocket for CAM services. The role of the health plan is to create a network of CAM providers offering a discount on charges. This initial approach may be attractive for the following reasons:

* Plans gain initial experience with CAM providers and vice versa; based on this experience, other products and approaches may evolve. For example, actuarial data could be gathered that could be used as the basis for pricing an insured product somewhere down the road.

* An uninsured product maintains the framework for accessing CAM therapy. At the present time, access to CAM providers is largely driven by patient self-referral. To many patients already accustomed to accessing CAM therapy on their own, extensive utilization management of CAM therapy, as expected with an insured product, may be perceived as an actual reduction in access. Currently, CAM providers are accustomed to operating their practices on a cash basis, and most of them have had little to no experience in working with a health plan. Therefore, many CAM providers may not be interested in participating in a network with cumbersome administrative requirements.

* An uninsured product would have no impact on health benefit premiums; the only expense would be establishing the network of discounted CAM providers. The product could be offered separately outside of health benefits.

An uninsured product could be structured in a variety of ways. For example, for an initial administrative fee, members could receive a discount card that they could use at any time for any provider in the CAM network. The patient would reimburse the CAM provider with out-of-pocket money. The initial administrative fee could even be offered as one of the options included in an employer's cafeteria-style benefits program. Alternatively, members could prepay for a certain number of visits or for a specific dollar amount of CAM benefits. Patients would still self-refer, and at each visit the appropriate units would be deducted from the prepaid amount. A co-payment could also be assessed.

The prepaid visits could also be offered as an option in a cafeteria-style benefits program. Prepaid visits would require the provider to submit a claim for reimbursement. Although this approach creates a greater administrative burden for both the CAM provider and the health plan, it does offer the opportunity to collect more information on the type of service provided, the reason the patient accessed the provider, etc. These data may provide some insight into the costs and utilization patterns of CAM therapy, and the impact on overall health care costs.

This data may be vital in future years if CAM therapy becomes more integrated into existing medical benefits. There is intense interest in CAM therapy at the present time, and if this persists, it is possible that it could become a mandated health benefit, similar to the situation in Washington state. Therefore, there may be an advantage to putting a process in place to collect utilization and cost data from the outset. A variety of hospitals and academic medical centers have developed a strong interest in CAM, particularly how CAM therapy can or should be integrated into biomedical care. Many of these centers may be looking for a research partner and may be able to provide expertise in setting up the appropriate research design and data collection systems.

No matter what system is chosen, the role of the primary care provider must be carefully considered. While patient self-referral may be advantageous for the reasons already discussed, leaving the primary care physician "out of the loop" may create its own problems. With the apparent endorsement by the health plan, patients may be more likely to ask their physicians for their recommendations regarding CAM therapy. Many physicians are unfamiliar, skeptical, or adversarial toward CAM; educational programs prior to the introduction of a CAM product may be considered. Even among those patients who do access CAM providers, few inform the physician about their use of alternative medicine. (1) At the very least, physicians should be encouraged to question their patients about CAM therapy.

2. An insured benefit

An insured CAM product, while permitting the collection of important utilization data, requires an administrative infrastructure to manage the benefit. Although this discussion does not focus on chiropractic medicine, the administration of chiropractic benefits may offer a useful model for other CAM benefits. The following strategies have been used:

* Setting a dollar cap

* Establishing a co-payment

* Requiring a physician referral

* Establishing a list of ICD-9 diagnoses that would be considered eligible for coverage

* Establishing a set number of visits per ICD-9 code

* Any combination of the above

Establishing a dollar cap can effectively limit utilization, but at the same time, it may create a sense of entitlement among members, such that there is an incentive to seek ways to spend up to the dollar cap. Co-pays may be an attractive option; although dated, studies have shown that chiropractic services are very sensitive to the existence of a co-pay, (4) additionally, co-pays may self select those patients in whom the CAM therapy is presumably working and would eliminate the casual or recreational users.

Requiring physician referral would imply that the physicians in a network understand and appreciate the appropriate uses of CAM therapy, thus requiring considerable education and "buy in" among existing providers. Establishing a list of ICD-9 codes and number of visits may require consultation with representatives of the CAM community. The resulting utilization management/coverage policies may thus represent more of a consensus process, rather than an evidence-based approach to coverage policy, which is often used in the development of coverage policies regarding biomedicine. Therefore, the potential exists for a double standard between the type of data required to support biomedicine and CAM therapies.

The potential double standard

This potential double standard may be of particular concern to health plans if the same contractual exclusions for investigational therapies apply both to CAM and existing biomedical therapies. The term investigational may be variably defined in different health benefit contracts, but, in general, many health plans and other policy-making organizations, such as the Agency for Health Care Policy and Research (AHCPR), have adopted an evidence-based or outcomes approach to the evaluation of medical technologies, as opposed to relying on evidence that a technology is widely accepted by the medical community. (5)

This approach endorses the use of objective outcomes data in published peer-reviewed journals as the basis for health policy, in part due to studies that have documented great variability in the practice of medicine, and in part due to the circular logic of a medical community standard. For example, one could predict the response if one asks the proponents of a medical technology if the technology is widely accepted among themselves.

Therefore, a fundamental question is whether the same coverage decision-making process can be applied to both CAM and biomedical therapies. Based purely on the CAM definition of CAM therapies, the answer is no, since, according to the CAM, therapies considered investigational by health plans may be defined as CAM therapies. Would CAM therapies pass muster according to an evidence-based approach? It is likely that the majority of them would not. Research in CAM therapies has lagged behind biomedicine, due to lack of funding from foundations and government support, whose budget has been largely controlled by the biomedical community.

In addition, corporate funding is negligible since many CAM therapies are based on nonpatentable services, such as herbal therapies or massage techniques. The CAM convened a panel to assess the practicality of developing clinical practice guidelines in CAM. This panel concluded that CAM Is currently unsuited to the development of practice guidelines due to the lack of outcomes data in controlled clinical trials. (G) In addition, the development of clinical trials addressing CAM therapies would be challenging, given that CAM therapies are individualized both in terms of diagnosis and therapy, thus limiting the application of uniform protocols.

Health plans may be concerned that coverage of CAM benefits may undermine coverage decision-making for biomedical therapies. The provision of CAM therapy based on standard health benefits contract language would imply that CAM was either (depending on the contract language):

* no longer considered investigational and there was adequate evidence in the peer-reviewed literature of its safety and effectiveness; or

* that it was widely accepted by the practicing community.

In terms of the first definition, coverage of CAM could create a precedent of a much lower standard of evidence that potentially could be applied to all other biomedical therapies that have long been considered ineligible for coverage. In terms of the second definition, coverage of CAM might create the precedent that the same process be used for biomedical therapy. For many policymakers, reliance on community standards instead of outcomes data represent a step backward, particularly for new technologies entering the system. (Another interesting debate might be whether such CAM therapies as acupuncture represent 'new' technologies.) On a contractual basis, It may be difficult to justify using one set of criteria (i.e., accepted by the CAM community) for CAM therapies and another (outcomes data) for biomedical therapies.

Establishing a CAM network

Credentialing is a major component of developing a CAM product, no mater what the benefit design. As discussed already, state licensure or certification by a professional society is a logical first step. Other requirements may Include:

* Some length of work experience to ensure that members access experienced practitioners;

* Proof of malpractice experience, although the number of claims flied against CAM providers has been minimal;

* Sufficient office hours-many CAM providers may only work part time;

* Adequate place of service; many CAM providers may work out of their homes or in their patient's homes. Restricting services to a dedicated office environment may limit the number of eligible CAM providers.

* Participation in quality improvement programs and outcome studies; taking part in these activities may be novel for some CAM providers. Many CAM providers may not routinely keep patient records or chart notes.

* Compliance with NCQA credentialing standards.

The future?

From a health plan perspective, the market demand for CAM benefits is intense. It will remain to be seen if this demand ultimately evolves into CAM benefits as a standard part of health benefits. Advocates of CAM look to the participation of health plans to help break down the barriers between conventional and alternative medicine. By collecting data regarding the use and outcomes of CAM therapies, the health plans can contribute to the answers to critical questions regarding CAM. Are CAM therapies effective? Do CAM therapies, with their emphasis on low cost prevention, reduce the overall cost of medical care?

Note

The Blue Cross and Blue Shield Association is an association of independent, locally operated Blue Cross and Blue Shield Plans. The information and views presented in this article do not necessarily represent the policies or views of either the Association or any of the Plans. This article should not be construed to mean that the Blue Cross and Blue Shield Association recommends, advocates, or requires the implementation, non -implementation, payment or non-payment, or coverage or non-coverage of complementary and alternative medicine.

References

(1.) Eisenberg, D.M., Kessler, R.C., Foster, C. et al. Unconventional medicine in the United States. New England Journal of Medicine 1993;328:246-52.

(2.) National Institutes of Health. Alternative Medicine: Expanding Medical Horizons. Washington, DC. National Institutes of Health, 1994.

(3.) Panel on Definition and Description, CAM Research Methodology Conference. Defining and describing complementary and alternative medicine. Alternative Therapy 1997;3:49-57.

(4.) Shekelle. P.C., Rogers, W,H,, Newhouse, J.P. et al. The effect of cost sharing on the use of chiropractic services. Medical Care 1996;34:863-72.

(5.) Woolf, S.H. Practice guidelines: A new reality in medicine: I. Recent developments. Archives of Internal Medicine 1990;150:1811-18.

(6.) Practice and Policy Panel, National Institutes of Health Office of Alternative Medicine. Clinical practice guidelines in complementary and alternative medicine. Archives of Family Medicine 1997;6:149-54.

RELATED ARTICLE: TRENDS IN THE DEVELOPMENT OF THE "INTEGRATIVE MEDICINE" CLINIC

Cedars-Sinai Medical Center in Los Angeles has taken the leap. So have Community Hospitals of Indianapolis, Presbyterian Healthcare in North Carolina, Stanford University School of Medicine, St. Joseph Medical System in Maryland, St. Elizabeth's Hospital in Massachusetts, University of Arizona School of Medicine, Hennepin Faculty Associates in Minneapolis, Kaiser Santa Rosa in California, and Catholic Healthcare West in Arizona. These substantial health care institutions are among dozens, nationwide, which have begun to offer an "integrative medicine" clinic or center as part of their system-wide facilities. These institutions are exploring the integration of alternative and conventional medical practices and providers under one roof. The list of integrative clinics steadily grows.

These integrative clinics represent one of the two dominant venues through which the burgeoning consumer interest in complementary and alternative medicine (CAM) integration is being explored by the medical mainstream. The other venue is coverage by HMOs and insurers through credentialed networks of CAM providers. Yet, while the CAM networks tend to be comprised of members of the distinct CAM professions (usually licensed chiropractors, acupuncturists, naturopaths, and massage practitioners), the integrative clinic tends to be centered around one or more medical doctors or osteopaths.

The seed of an integrative clinic is usually the personal interest in CAM of a system physician or executive. A physician may approach the organization's executives with a proposal to add CAM services. Conversely, one or more executives interested in CAM may recruit physicians to serve on a CAM steering committee. The core argument may be paraphrased as follows:

Patients want CAM. They are going to get these alternatives somewhere. So let's offer [CAM] under physician supervision. CAM users won't cut themselves off from conventional services. We can assess outcomes. There are certainly some areas where our conventional therapies come up short. Maybe some of these alternatives can be effective or even cost-effective.

Meantime, the system's CFO, who will have heard of the billions spent out-of-pocket by CAM patients, is thinking: If this can turn a profit, or at least break even, we can keep income from these alternative services in-house. Even if it's not a profit center, we will retain the loyalty of our patients who will be here when they need more serious interventions.

Substantial variations in models

Clinical strategies, organizational models, and financial outcomes in integrative clinics vary significantly. THE INTEGRATOR for the Business of Alternative Medicine recently reported the first set of data from an ongoing benchmarking survey in the integrative clinic field (Vol. 3, No. 3, October 1998, 1, 4-6). Six clinics are profiled in-depth on: general characteristics, clinical services, personnel, marketing, research/outcomes, and revenue and expense. While a limited set, the findings corroborate earlier reports. (See especially the article by Kenneth R. Pelletier, American Journal of Health Promotion 1997:12(2):112-123.)

These clinics are young. Three started up in 1998. Three were formed inside health systems, a fourth with close alliances to an academic center, a fifth via venture capital, and the sixth by an individual practitioner. They range from 1,400 to 10,000 square feet, and from 2.6 full-time equivalent (FTE) providers to more than 30 FTE providers.

* CAM therapies and practitioners

Acupuncture, nutrition, massage, mind-body relaxation, and group-delivered services, such as tai chi, yoga, and support groups were the leading services. Also frequently offered are psychological counseling and homeopathy Naturopaths are on staff in three of the clinics and chiropractors in two. All but one have a natural products dispensary with total vitamin and botanical products ranging from 50 to more than 200. Most have some laboratory services onsite, while also contracting with specialty CAM laboratories for tests which are more familiar in the CAM arena (i.e., adrenal saliva, allergy testing, and stool analysis).

* Conventional services

While all may be called "integrative," the percent of services viewed as "conventional" varied from zero to 80 percent. The clinic on the high end, the Arizona Center for Health & Medicine (ACHM), sponsored by Catholic

Healthcare West, projected a decrease to 30 percent in conventional services within the year, a figure which approximates the average for those offering conventional services. ACHM is shifting from principally physician-delivered or nurse-delivered CAM services to increased use of other alternative providers. This appears to be a trend in the integrative clinic field--as organizations become more comfortable with CAM, they begin to work directly with the distinct CAM provider categories.

Revenues

Some held this data as proprietary. Of those responding, most projected the clinics to break-even in 12 to 24 months. The expectation is not of significant profits, although all expect to run in the black. Self-pay is the major form of income. Third party reimbursement is minor, although most noted focusing some marketing energy in developing relationships with these payers. None were yet assuming risk on contracts. In phone interviews, managers expressed some uneasiness about the revenue picture. This uncertainty and limited data does not appear to be deterring many systems. Some, like Deaconess Healthcare in Evansville, Indiana, are proceeding with caution, in a stepwise fashion. At the same time, others are jumping with both feet: a four-hospital New York City group led by Beth Israel, Continuum Partners, recently made a $5 million commitment toward an integrative medicine clinic.

John Weeks is the Publisher-Editor of THE INTEGRATOR for the Business of Alternative Medicine, a monthly newsletter focusing on CAM integration and payment issues, in Seattle, Washington. Review copies of the October INTEGRATOR are available to The Physician Executive readers by calling 206/933-7983, faxing 206/933-7984, or emailing a request to pihcp@aol.com. Susan McBroom of the Washington, D.C. based consulting firm, HealthLINX, is collaborating on the benchmarking project.

Elizabeth Brawn, MD, is National Medical Director for Blue Cross Blue Shield Association in Chicago, Illinois. She can be reached by calling 312/297-6186 or via email at Elizabeth.Brown@bcbsa.com.

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