Doctors in HMO embrace alternative therapies

Study: Patients, providers interested in therapies

A recent study conducted by Kaiser Permanente in Oakland, CA, found that nearly 90% of the health plan’s primary care providers had provided or recommended alternative therapies to adult plan members in the previous 12 months, primarily for pain management.

Perhaps even more surprising were the reasons providers listed for recommending alternative therapies, says Nancy Gordon, ScD, research investigator with the division of research medical care program at Kaiser Permanente in Northern California and the study’s lead author.

"When we asked clinicians which set of factors motivated their interest in alternative therapies, the leading motivator was a belief that patients could not be adequately treated by more conventional methods," she notes. "The second most common motivator clinicians listed was a belief that many health problems, such as menopause, osteoporosis, and premenstrual syndrome (PMS) could be treated more effectively using a holistic approach."

The study found the alternative therapies most commonly recommended or practiced by Kaiser providers include chiropractic, acupuncture, massage therapy, biofeedback, and relaxation techniques. Only 10% of providers used or recom - mended herbal or homeopathic medicine. How ever, of all providers, women’s health providers expressed more interest in herbal medicine.

More than 60% of adult care providers and roughly 75% of women’s health providers said they wanted Kaiser to provide greater access to alternative therapies. Less than 15% of all providers surveyed said they absolutely did not want the HMO to offer greater access to alternative therapies.

Other study findings include the following:

• 31% of members had used at least one alternative therapy in the past 12 months.

• 50% of members had used an alternative therapy at least once in their lifetime.

• 93% of providers had used or recommended at least one alternative therapy listed on the survey in the past 12 months.

"When we took psychological counseling, special diets, 12-step programs, and prayer out of the mix, that fell to 89%," Gordon says. Simi larly, when the same therapies were removed from the member list, the percentage of members who had used alternative therapies in the past 12 months fell from 31% to 25%. "If health plans are going to be serious about looking at what alternative therapies they’re going to provide, they need to understand what their members are using, what their doctors are recom mending for what types of problems, and where the two overlap."

"We take these findings very seriously," says Harley Goldberg, DO, regional coordinator of complementary and alternative medicine for The Permanente Medical Group, which delivers care to the 2.8 million Kaiser Permanente members in northern California. "We’re working rapidly to make those therapies that are safe and effective available to our members."

Goldberg says Kaiser set up an advisory panel of clinicians and alternative therapy experts to use an evidence-based approach to evaluate the efficacy and safety of alternative therapies. "If there is no evidence to support the use of a particular therapy, we’ve agreed to go no further in providing that therapy," he notes. "In some ways, that creates a downside because I’m sure there are alternative therapies which are effective but for which no evidence yet exists."

The next issue the advisory panel must tackle is quality delivery, he notes. "How do you determine who is the qualified practitioner to deliver an alternative therapy? For acupuncture, you have physicians who practice acupuncture, and there are licensed acupuncturists. And which are the best delivery systems? Do you bring the service in-house?"

There also are issues of adverse effects and contraindications to consider, such as herb/drug interactions, he says. "Roughly 75% of patients who are using alternative therapies don’t mention it to their primary care provider, even when the provider asks a direct questions. It’s clear that providers get more information when they ask about alternative therapy use than they do when they don’t ask. Part of our job is to educate our providers about alternative therapies and to encourage them to question their patients about alternative therapies. About 75 out of 100 patients will answer honestly, if their provider ask them direct questions about which alternative therapies they use."

[See also: Gordon N, Sobel DS, Tarazona EZ. Use of and interest in alternative therapies among adult primary care clinicians and adult members in a large health maintenance organization. West J Med 1998; 169:153-161.]

How They Did It

Researchers at Kaiser Permanente in Oakland, CA, conducted three surveys with questions relating to alternative therapy use.

o In the spring of 1996, the large health maintenance organization (HMO) mailed surveys to 3,000 health plan members and all primary care providers working in adult medicine, plus a random sample of women’s health providers, including obstetricians/gynecologists and nurse practitioners.

o More than 750 providers, including 624 adult primary care physicians and 157 women’s health providers responded to the provider survey.

o More than 1,500 adult health plan members responded to the member alternative therapy survey.

o Providers and adult plan members were asked to answer questions about their experience with 20 alternative therapies, including acupuncture, chiropractic, and herbal medicine.

o In addition, several questions about alternative therapies were added to the member health practices survey the HMO conducts every three years.

o Of the 34,000 adult members surveyed, 17,735 completed and returned surveys on health practices.

o Kaiser also conducted phone surveys with a random sample of non-responders to both the provider and member alternative therapy surveys to make sure findings were consistent with those on returned surveys.