Articles

Obamacare and CAM III: Great Expectations

In a previous post, we looked at how so-called “complementary and alternative medicine” (or “CAM”) might fit into the definition of “essential health benefits,” which must be covered by insurers pursuant to the Patient Protection and Affordable Care Act (“Obamacare,” or the “ACA”). In another, we contemplated what it might mean for insurers to “discriminate” against CAM providers, which is prohibited by the ACA. In both posts, the conclusion reached was that these provisions of Obamacare might not incorporate CAM practices into health care at the level CAM providers were hoping for. Here again we examine how the great expectations of CAM promoters may not be met in health care reform.

This time, we take a look at some additional provisions of the ACA that CAM lobbyists and their friends in Congress managed to insert into the healthcare overhaul. Of course, whether the ACA is around for much longer will depend on the outcome of the November elections, although Gov. Romney’s promise to “repeal Obamacare” if elected president will happen only if his party wins a majority in both the House of Representatives and Senate. 

Patient-Centered Medical Home

As part of its effort to bring down costs and improve healthcare, the ACA is all about primary care. Every person is to have a primary care physician coordinating his care, ideally in what is known as the “Patient-Centered Medical Home,” or “PCMH.” This is how the Kaiser Family Foundation defines the idea:

A health care setting where patients receive comprehensive primary care services; have an ongoing relationship with a primary care provider who directs and coordinates their care; have enhanced access to nonemergent primary, secondary, and tertiary care; and have access to linguistically and culturally appropriate care.

Actually, the PCMH existed as a model of health care delivery before the ACA, which simply adopted its tenets. It was largely developed by the by the National Committee for Quality Assurance [NCQA] with input from the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics and the American Osteopathic Association. Notably absent from this list are any CAM provider organizations. From this collaboration NCQA developed a “Physician Practice Connections Recognition Program” as a gold standard for medical practices. This model forms the basis of the NCQA’s PCMH Recognition Program, which allows PCMH-recognized practices to take advantage of financial incentives offered by health plans and employers as well as government-sponsored programs, including grants and contracts offered by Medicare and Medicaid under the ACA.

And guess who wants to be primary care providers under the ACA? Chiropractors.

NCQA has six “must pass” standards for PCMHs the application of which to any chiropractic practice will guarantee that no chiropractor will head a PCMH. One of these is that the PCP must “Plan and Manage Care” and chiropractors simply do not have the education and training to manage the wide range of conditions seen by a PCP. Three features of the care management requirement are deal-killers. Patient management has to include the ability to implement evidence-based guidelines. As Harriet Hall has amply demonstrated even those who advocate most strongly for DCs as PCPs are unable to do this. As well, their “education programs” (actually, hotel conference room seminars) for primary care are grossly inadequate for actual practice as a PCP. Another is the requirement that the PCMH be able to manage medications and have the capacity for electronic prescribing. Since chiropractors can’t prescribe the vast array of medications necessary for primary care practice their becoming PCPs is simply a non-starter.

Apparently unaware of the rigorous standards for PCMHs, The Foundation for Chiropractic Progress issued a white paper on “The Role of Chiropractic in the Patient-Centered Medical Home.” Most of the document advocates for the chiropractor as a provider of services for back and neck pain and headaches. But, ever the optimists, the chiropractors assert that they also have a role as primary care providers, a subject we’ve addressed here (and here and here) at SBM a number of times. The paper provides these reasons in support:

  • Patients may use a DC as a first point of contact within the healthcare system. (True, but they don’t do it for primary care.)
  • The American Chiropractic Association thinks it’s a good idea.
  • The Joint Commission recognizes DCs as “physicians.” (True, but also podiatrists, dentists and optometrists, and no one is claiming they are PCPs.)
  • Two states define DCs as PCPs.

Wow. I’m convinced, aren’t you?

In fact, it doesn’t appear Congress had DCs as PCPs in mind at all when it drafted the ACA. The law provides money for more training in family medicine, general internal medicine, general pediatrics and physician assistants, but not DCs. The ACA also supports the creation of Community Health Teams through grants and contracts with HHS. These teams are “to provide support services for primary care practices” which, to be eligible for federal money, shall:

Ensure that the health team . . . includes an interdisciplinary, interprofessional team of health care providers, as determined by the Secretary [of HHS]; such team may include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral and mental health providers (including substance use disorder prevention and treatment providers), doctors of chiropractic, licensed complementary and alternative medicine practitioners and physicians assistants.

If Congress thought DCs could be PCPs, why would it include DCs among the optional members of the health team run by the PCP?

Finally, Medicare, the source of funding for many of HHS’s demonstration projects, covers chiropractic only for “subluxation” correction. Despite what Daniel David Palmer thought that simply won’t do as primary care.

Even as part of the “health teams” supporting PCPs it looks like there may not be much of a role for chiropractors and other CAM providers whose selection as part of the team is optional. Proponents of CAM and “integrative” medicine are all excited about this provision because it specifically mentions them!!! Their enthusiasm might well be tempered with a look at a few other provisions. The ACA also provides that:

In addition, the health team must:

Provide coordination of the appropriate use of complementary and alternative (CAM) services to those who request such services.

So, in sum:

  • CAM must be provided only to those patients who request such services and its use must be “appropriate.”
  • Medical team care must be “safe and high quality care through evidence-informed medicine . . . and continuous quality improvements.”
  • Care must be cost-effective.
  • Providers must “collect and report data that permits evaluation of the success of the collaborative effort on patient outcomes” and identify areas for improvement.
  • Providers must provide a care plan to the team for each patient and access to the patient’s medical records.

In other words, CAM providers will have to practice in a setting unlike any they have ever seen and will have other health care providers looking closely at what they do. I seriously doubt your usual CAM providers will be prepared for this kind of scrutiny, cost control limitations and performance evaluations. Nor will they be allowed to perform such nonsense as cupping, applied kinesiology and cranial sacral therapy and the like. (But wouldn’t you just love to see the PCP’s face when that report came up in the patient’s medical record?)

Accountable Care Organizations

One of the other key patient care/cost saving devices of the ACA is the Accountable Care Organization, which the Kaiser Family Foundation describes thusly:

A network of health care providers that band together to provide the full continuum of health care services for patients. The network would receive a payment for all care provided to a patient, and would be held accountable for the quality and cost of care. Proposed pilot programs in Medicare and Medicaid would provide financial incentives for these organizations to improve quality and reduce costs by allowing them to share in any savings achieved as a result of these efforts.

Whether this model will work is the subject of some debate. And whether ACOs will incorporate CAM providers is not clear. Even an article in the CAM-friendly Journal of Alternative and Complementary Medicine, funded by (surprise!) the National Center for Complementary and Alternative Medicine (NCCAM), could make only a weak case for inclusion. The authors’ pro-CAM argument centered mostly around the fact that CAM is popular and there are a lot of CAM practitioners, both of which are irrelevant to their inclusion in ACOs. And they optimistically note that the “developing empirical evidence on both cost and efficacy of CAM from ongoing research activities funded primarily by [NCCAM] will likely help inform which CAM services might be included in ACOs.” I find their enthusiasm misplaced, as I know of no research which would support CAM inclusion in ACOs.

But even these authors were forced to admit that “due to extreme diversity among CAM providers and newly emerging modalities . . . it [is] difficult to consistently define what constitutes CAM,” a point we here at SBM have made numerous times. I do have to admire the careful wordsmithing which resulted in the phrase “newly emerging modalities,” or what we might less charitably describe as “things people make up.” As well, “unless long-term benefits of CAM use for general health are proven empirically, CAM use for general health in ACOs will be controversial.” I would say “non-existent,” as no ACO is going to tolerate unproven treatments bringing down the all-important bottom line, which means less money for the other providers. Finally, “should CAM practitioner services become involved in ACOs, monitoring appropriate use will likely be a considerable challenge.” In other words, they aren’t used to being watched.

Naturopaths made their own pitch for inclusion in ACOs. While the American Association of Naturopathic Physicians (AANP) correctly noted that naturopaths aren’t covered providers under Medicare (which operates the ACA’s ACO demonstration projects), they nevertheless implored HHS to consider them in a 2011 letter. In addition to the ubiquitous “CAM is popular” argument, they claimed that naturopaths are “highly trained primary care providers” whose standards are “on par with that of conventional medicine” who “play a significant role in reducing the rate and impact of chronic disease in underserved populations,” assertions all nicely refuted in a series of posts by Kimball Atwood, collected here.

In their plea to HHS, the AANP could come up with only two studies to support their broad assertions of quality care. One was a small study of patients with back pain comparing the cost-effectiveness of “naturopathic care” (acupuncture, relaxation exercises, exercise and dietary advice, and a back care booklet) compared to standardized physiotherapy education and a back care booklet. The other was unpublished results from a “randomized controlled pragmatic trial of the whole practice of naturopathic medicine.”

CAM on Board

The ACA also creates a number of Boards, Commissions and the like to provide advice on the healthcare system. CAM proponents managed to require that CAM providers be included as members.

One of these new bodies is the National Health Car Workforce Commission, which the American Association of Family Physicians describes as:

dedicated to making recommendations regarding health care workforce issues. According to some analysts, this commission could emerge as the dominant force in driving and shaping the nation’s health care workforce policies. . . . The commission will make recommendations to Congress, the U.S. Department of Labor and HHS on a broad range of workforce-related topics, including national workforce priorities and goals, current and projected workforce supply, and needs and assessments of current education and training activities.

The fifteen initial members were appointed in 2010, but nothing happened after that because Congress never provided funding. The members hold MD, RN, PhD, MPH, DDS, and JD degrees. There are also a couple of health care executives but no CAM practitioners.

Where the ACA requires inclusion on other advisory bodies, CAM practitioners appointed hold advanced degrees as well as their CAM degrees and are but a few among many other practitioners, including MDs, RNs, dentists, MPHs, PhDs and the like, all with their own agendas. For example, CAM proponents seemed very excited about the  Advisory Group on Prevention, Health Promotion, and Integrative and Public Health Council, which has one acupuncturist who is also an RN and Catholic nun on board (go figure). It also includes Dr. Dean Ornish. However, if the minutes of the first meetings are any indication, CAM is pretty much being ignored.

Be careful what you wish for

I wonder if CAM practioners really want to be a part of health care reform and question their enthusiasm at being included. It seems the last thing CAM providers would welcome into their practices is greater accountability, more supervision by MDs, DOs, PAs and nurses, access to their patient records, application of evidence-based standards, and required demonstrations of cost-effectiveness, all of which they’ve pretty much avoided to this point.

Posted in: Acupuncture, Chiropractic, Legal, Naturopathy, Politics and Regulation

Leave a Comment (9) ↓

9 thoughts on “Obamacare and CAM III: Great Expectations

  1. Chris Repetsky says:

    The one thing I do fear is if CAM practitioners are working under the supervision of real physicians, what if those physicians take the “shruggie” attitude or the “what’s the harm?” style to managing their CAM underlings? I honestly don’t know how much tolerance most real physicians have for CAM, but I do know that quite a few I’ve spoken to in my career as a medical student take one or both of those attitudes towards it.

    I just hope that this doesn’t give them a foothold towards gaining any more undeserved legitimacy. But all that aside, I support the ACA and think it’s a step in the right direction for us.

  2. windriven says:

    I wish I shared Ms. Bellamy’s optimism on this issue. The political process concerns itself with managing the satisfaction of wants of diverse groups of people. The noisy interests and the monied interests do well in this process for the same reason: they are perceived to be able to deliver votes.

    Healthcare consumes nearly 20% of GDP now and has become increasingly shaped by the political process. The nation cannot continue to spend a fifth of its output on healthcare and remain competitive. So efforts – and ACA marks more the beginning than the end of these efforts – will mount to reduce the share of GDP devoted to healthcare; an especially difficult undertaking given the demographic realities facing us in the next 40 years. Yet it is these same realities that militate for controlling healthcare costs especially those costs devoted to non-productive cohorts (the elderly).

    Physicians are scarce and expensive resources. Seats in medical schools are climbing but too slowly. PAs, NPs, and a gaggle of sCAM artists and chiroquacksters will scrum to fill the void and at a significantly lower cost than MDs. My guess is that Medicare and Medicaid will slowly but inexorably open their arms to DCs and others for this reason.

    Stopping sCAM in its tracks in the political realm is going to take more than a logical exposition of science based medicine. And if we don’t stop it in the political realm, we don’t stop it at all.

  3. Chris Repetsky says:

    @windriven

    Do you think that if Medicare/Medicaid starts turfing unfortunate patients to Chiros and their unqualified ilk, that eventually the shift in quality of healthcare in the years to come would persuade them to rethink this decision? I would wager an educated guess that we’d see a decline in the quality of care if DCs are acting in bigger roles without further training (and perhaps even re-learning of the pseudoscience they are bombarded with in Chiro school) and wonder if this might clue the powers that be into the fact that something’s amiss?

    Then again, lobbyists are incredibly powerful, and those in charge really haven’t changed their minds on woo before, so I suppose it stands to reason that they wouldn’t budge. Sad, really.

  4. weing says:

    “Physicians are scarce and expensive resources. Seats in medical schools are climbing but too slowly. PAs, NPs, and a gaggle of sCAM artists and chiroquacksters will scrum to fill the void and at a significantly lower cost than MDs.”

    Check out this article. They are already talking about expanding the scope of PAs and NPs. They may also indemnify them from lawsuits. I’m sure that will ostensibly save money. Maybe they will allow rustichealthy to ply her baking soda and vitamin cures.

    http://www.nejm.org/doi/full/10.1056/NEJMsb1205901

  5. Scott says:

    I would say “non-existent,” as no ACO is going to tolerate unproven treatments bringing down the all-important bottom line, which means less money for the other providers.

    Given that HMOs already have those same incentives, but nevertheless often cover chiropractic and acupuncture in particular, this seems quite over-optimistic to me.

    Overall, my impression of this series has been that it may be summarized as “if the best scientific evidence is followed, CAM will not be promoted by Obamacare.” Well, if the best scientific evidence were followed, CAM would not exist. Hence we can’t reasonably assume that it will be followed in this context either.

  6. windriven says:

    @Chris Repetsky

    ” that eventually the shift in quality of healthcare in the years to come”

    I don’t want to sound entirely cynical but the thought will not be lost on the political class that old, sick people are too big a financial burden. In other words yes, the shift in quality will be recognized but no, that wouldn’t necessarily lead to a change in policy.

  7. windriven says:

    @weing

    Thanks for the link. I’m slammed this morning but look forward to reading it carefully at lunch.

    PAs and NPs are definitely part of a rational solution. I just fear that embracing sCAM will be attractive to those shaping healthcare policy. The sCAM rabble gets quieted for less money than it would cost to force them to get care from a physician-centered practice. From a politician’s standpoint, what’s not to like?

  8. windriven says:

    @weing

    You linked to a really interesting editorial in NEJM. Some of the approaches they suggested are clearly doable and desirable; some are less likely including, in my estimation, physicians groups passively watching a wholesale expansion of independent practice limits for paraprofessionals*; and a few were clearly daydreams (a panel of technocrats setting spending targets – that would intrude on what Congress sees as its perquisites).

    *And for what little it is worth I believe that PAs and NPs should operate under the supervision of a physician. I’m all for having, say, a CRNA handle my general but if everything goes pear-shaped I want an MD anesthesiologist nearby.

Comments are closed.