Groups struggling to integrate new therapies

Experts offer advice on adding alternative care

Disease and management are not terms chosen by most alternative providers to describe their treatment philosophies. Most managed care plans now offer benefits for acupuncture, massage therapy, and chiropractic treatments. Nationwide, managed care organizations (MCOs) are working on disease management models that integrate alternative and conventional providers.

"Chronic disease is often what moves people to seek alternative providers. Patients aren't pleased with the conventional treatments they've received. Often they have chronic complaints that don't improve with conventional treatment," says John Weeks, a consultant with Integration Strategies for Natural Healthcare in Seattle.

One large Seattle MCO is developing disease management guidelines for sinusitis, Weeks says. "They have brought naturopaths to the table with conventional providers to see what guidelines would look like if alternative and conventional providers both brought their research and knowledge base to the table."

"There are many positive reasons to look at integrating alterative and conventional therapies," says Kerry Hardwood, RN, director of the cancer patient education program at Duke University Medical Center in Durham, NC. "However, integration cannot occur without a paradigm shift. That's why it's important to move slowly. The best shift is not to see how to fit alternative medicine into conventional medicine, but rather to look at what alternative medicine has to offer and make changes on both sides."

Others agree. "Everybody is talking about integration. It's very fashionable," says John Pan, MD, director of the Center for Integrative Medicine at George Washington University Medical Center in Washington, DC. "This is an evolving story. It involves a shift in thinking, and it's going to take a while. It's a business opportunity, but more importantly, it's an opportunity to reshape the health care delivery system."

There are both benefits and barriers to MCOs adding alternative providers to their disease management programs, Hardwood says. Some of the benefits include the following:

o Recruitment. "Offering alternative therapies is a good recruitment strategy," she says. "It's a way for health plans to differentiate themselves from their competitors. We get patients at Duke who come to us for our music therapy and stress management nurses. We have patients who come from out of state because they like our approach, which allows them to be actively involved in their healing."

o Satisfaction. "Offering choice, empowering patients, and giving patients hope is what alternative therapies do best. Sometimes healing does not involve curing but is much more meaningful. This leads to high levels of patient satisfaction," she says.

o Outcomes. "Although conventional medicine often criticizes the lack of solid research available on outcomes for alterna tive therapies, there are several areas where research shows alternative therapies are at least as effective and less toxic than traditional treatments," Hardwood says.

o Lower cost. "Many patients pay out of pocket for alternative therapies," she says. "If we look at total cost rather than cost-shifting from the plan to the patient, many alternative medicine strategies are less expensive than traditional therapies."

Of course, there also are barriers to integrating alternative therapies into MCOs. "Some of these barriers require large shifts in our approach to patient care and must not be underestimated. Others are more easily addressed," Hardwood says. They include:

o Passive patients. "Alternative therapies require active patient involvement. Americans are used to being directed what to do by their physicians. Some patients are not comfortable taking a more active role in their own health care," she says.

o Physician discomfort. "Physicians are often uncomfortable with alternative therapies and the model of the empowered patient. You must take time to prepare your conventional providers for this shift before integrating alternative therapies into your disease management programs," she cautions.

o Lack of physician referrals. "Many managed care models require physician referrals for treatment by other providers," Weeks says. "If a patient's primary care physician is antagonistic toward alternative services, the referrals won't come." He suggests MCOs remove this barrier in two ways. "First, you have to aggressively educate both your providers and members about the alternative benefits and services you offer. If you make something a benefit, and no one knows about it, referrals won't come," he says. "Second, you have to have an alternative mechanism for referrals within the system. Create an administrative or care coordinator role to help patients work around the problem of antagonistic physicians."

Should patients be empowered?

o Selecting appropriate alternative providers. "There are significant challenges to selecting appropriate alternative therapies and outcome measures that are tied together," says Hardwood, adding that the Office of Alt ernative Medicine (OAM) in Bethesda, MD, has more than 100,000 research trial citations for alternative therapies. In addition, the OAM provides lists of schools and accrediting bodies for alternative providers.

"Many of the traditional measures of morbidity and mortality relied on for conventional research don't apply well to alternative therapies," Hardwood says. "More appropriate measures are patient satisfaction, ability to work, participation with health care, and changes in pain levels."

Duke now uses educational strategies to empower patients. she helps patients access a broad range of health education materials. "We coach patients and their families to be very active in their health care," she says. "The model is well-met by patients, but not by providers. Physicians aren't comfortable with empowered patients. One physician told me half of the materials in my medical library should be burned."

The Duke oncology program addresses spiritual, psychological, nutritional, and physical aspects of health and treatment with a heavy emphasis on education throughout, he says. "We have written an alternative therapy guide for cancer patients as part of our normal offerings. This is especially vital in oncology. Studies indicate that 50% of cancer patients use some kind of alternative therapy. In addition, 57% of all inquiries received by the OAM are for cancer."

Baby steps are key to successful integration of alternative therapies into disease management programs, Hardwood says. "Focus on making information about alternative therapies available to conventional providers, so that they become increasingly more comfortable with the benefits of alternative providers."

Alternative providers also need reassurances, she adds. "Alternative providers don't always want to come into a conventional system. They feel that coming into a physician-controlled environment threatens the quality of their practice," she explains.

There is some evidence to support that fear. "For example, studies show that if physicians are not supportive of nutritional recommendations to breast-feed, it hampers a woman's efforts and causes her to discontinue breast-feeding," she says.

Use different outcome measures

In addition, MCOs must realize they can't use the same outcome measures for alternative therapies as they use for other treatment modalities. Hardwood says appropriate measures for alternative therapies include the following:

o patient satisfaction;

o patient/provider relationship;

o patient readiness to change;

o patient lifestyle changes.

"At present, we are stuck with an evidence-based model of research for alternative therapies. Many of the current studies on alternative therapies are significantly flawed," notes Pan. "None of them truly meet the standard medical model. We need to actively participate in the data collection process to show whether or not these therapies really work," he says.

"We can argue about the value of alternative therapies all day, but in order to play the game and truly shift the paradigm, we have to be able to show how it works," Pan says.

For more information, contact:

· Kerry Hardwood, RN, director of cancer patient education, Duke University Medical Center, Erwin Road, Durham, NC 27710. Telephone: (919) 684-8111.

· John Pan, MD, director, Center for Integrative Medicine, George Washington University Medical Center, 2150 Pennsylvania Ave., Washington, DC 20036. Telephone: (202) 994-1224.