CAM & Health Reform Thompson and Nichter, 2011

Transcription

1 Complementary & Alternative Medicine in the US Health Insurance Reform Debate: An Anthropological Assessment is Warranted Jennifer Jo Thompson 1 and Mark Nichter 2 The National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health defines complementary and alternative medicine (CAM) as a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine (NCCAM 2011). While this flexible definition allows specific practices to move between CAM and conventional medicine, in general CAM practices include the use of natural products (most of which are regulated as dietary supplements); mindbody practices like yoga, tai chi, meditation; manipulation and body-based medicine including chiropractic and massage therapy; as well as other CAM modalities, including energy medicine (e.g., Reiki) and Whole Systems of healing (e.g., naturopathy, homeopathy, traditional Chinese medicine, ayurveda). CAM represents a small, but important segment of the US healthcare economy. According to data collected in the 2007 National Health and Nutrition Examination Survey (NHANES), nearly 4 out of 10 Americans used some form of CAM in the last 12 months (Barnes, et al. 2008). Furthermore, US adults spent nearly $34 billion out-of-pocket dollars on CAM in 2007, accounting for 1.5% of total US health care expenditures and 11.2% of total out-of-pocket health expenditures. Of these out-of-pocket CAM dollars, one-third ($11.9 billion) were spent on visits to CAM practitioners (Nahin, et al. 2009). Analyzing data from the 2007 NHIS, Davis et al. (2011a) identify two distinct groups of CAM users: those using CAM for wellness and health promotion (27.4% of the US adult population) and those using CAM for the treatment of disease or illness (17.4%). Among both groups, the vast majority of CAM use is complementary rather than alternative to biomedical care (IOM 2005). In fact, nearly 4 out of 5 CAM users surveyed in 1997 agreed that using both CAM and conventional medicine was better than either one alone (Eisenberg, et al. 2001). Furthermore, of the CAM users who had visited a CAM practitioner (most often chiropractors and massage therapists), over half had seen a biomedical practitioner first. Nevertheless, there is growing evidence that small segment of Americans (approximately 4%) generally those who lack health insurance are using CAM as an alternative to conventional medical care (Nahin, et al. 2010). Those using CAM as an alternative are more likely to be poorer and in worse health than those forgoing both conventional and CAM over the last 12 months. Furthermore, those using alternative medicine were more likely to have delayed conventional care, with one-fifth reporting that they chose alternative medicine because of the expense of conventional care. Given that the vast majority of CAM use is paid for out-of-pocket, these numbers likely under-represent the potential reach of CAM if it were widely covered by health insurance. Data from Washington State, which has mandated insurance coverage for services by licensed CAM providers since 1996, offers insight on the impact of insurance coverage on CAM use and cost. Analyses of patterns of CAM use and the effect of CAM use on health care expenditures in Washington State indicate that although many patients will use CAM if covered by insurance, it 1 University of Georgia, jjthomp@uga.edu 2 University of Arizona, mnichter@ .arizona.edu 1

2 has only modest effects on healthcare expenditures, with lower inpatient and imaging costs making up for increases in outpatient costs (Lafferty, et al. 2006; Lind, et al. 2010). 3 Currently, CAM coverage is highly variable based on state mandates, and the licensure or certification of CAM practitioners, and insurance companies and plans. Nevertheless, most private and public insurance plans offer some CAM coverage (most notably chiropractic manipulation), although this usually includes limitations on which services are covered for specific conditions, as well as limitations on the number of visits covered (Cleary-Guida, et al. 2001; Pelletier and Astin 2002; Steyer, et al. 2002). In recent years, there has been increased interest in questions about the expansion of patient access to CAM (Duncan, et al. 2011; Vos and Brennan 2010), the integration of CAM into existing and emergent health systems (Davis, et al. 2011b; Gilmour, et al. 2011), and the barriers to the widespread expansion of insurance benefits for CAM therapies (Tillman 2002). 4 The passage of the Patient Protection and Affordable Care Act (PPACA), which aims to vastly expand health insurance coverage in the US and expressly forbids health insurance providers to discriminate against any health care provider who is acting within the scope of that provider s license or certification under applicable State law (Section ), provides an historic opportunity to consider whether and how CAM should be broadly integrated into US health insurance schemes. Nevertheless, insurance coverage for CAM is a thorny issue that raises a whole host of questions: What are the potential effects of CAM coverage on the provision, use, and expense of CAM and conventional health care services? What effect does CAM coverage have on individual and public health outcomes? Considering the diversity of CAM modalities, what criteria are used to determine (and justify) what CAM services are covered or denied? How should the impact and value of CAM be evaluated alone and in combination with conventional and mental health care? Anthropologists are ideally-suited to investigate these and other questions related to the issue of health insurance coverage of complementary and alternative medicine. In the remainder of this essay, we suggest a series of key research questions related to health insurance coverage for CAM where anthropologists can make substantive contributions: 1. Given the need to control health care costs, why would insurance companies (public/private) expand coverage to CAM therapies? Indexing the shift from a top-down, Doctor-Knows-Best paradigm to a Patient-Centered paradigm, the inclusion of CAM in health insurance plans responds to patient-demand for CAM coverage by those using CAM for health promotion, as well as those using CAM for disease management. It also responds to broader patient demands for increased choice and agency in health care decision-making (Pelletier and Astin 2002). Nevertheless, there is need for research examining the ways in which CAM coverage fulfills additional goals on the part of health insurance companies: to save money 3 Lafferty and colleagues (2006) found that although nearly 1 out of 7 enrollees in the three large insurance companies made CAM claims in 2002, the median cost of CAM visits was significantly less than conventional outpatient visits ($39 vs. $74.40), and CAM visits accounted for only $75, less than 3% of overall expenditures, per enrollee. In similar analyses, CAM visits accounted for less than 2% of total expenses for cancer patients, diabetes patients and pediatric enrollees (Bellas, et al. 2005; Lafferty, et al. 2004; Lind, et al. 2006). Furthermore, among fibromyalgia patients, although CAM users had more outpatient visits, health expenditures for CAM users were similar to non-users because CAM visits were less expensive than conventional visits (Lind, et al. 2007). 4 Tillman (2002) identifies three key barriers to the widespread expansion of benefits for CAM therapies by thirdparty insurers: the scarcity of high quality scientific data demonstrating the efficacy of CAM therapies, inconsistencies in the licensing and regulation of CAM providers, and difficulties classifying CAM interventions according to standardized diagnosis/treatment-based reimbursement schedules. 2

3 by offering CAM therapies that are cost-effective in comparison to conventional care; to bolster and market a corporate/public image as enlightened, concerned with wellness and responsive to patient-interests; and, finally, to encourage a neoliberal will to health that emphasizes personal responsibility for engaging in prudent behaviors on the part of health care consumers (Rose 2001, p. 6; Vos and Brennan 2010). 2. Given an emphasis on evidence-based medicine as a means to control both the cost and quality of health care, how should the effectiveness of CAM be evaluated? For a number of reasons related to problems with appropriate controls, blinding, and standardization of protocol, CAMs have generally not performed well in randomized controlled trials (RCTs) measuring specific efficacy (Carter 2003; Verhoef, et al. 2002; Verhoef, et al. 2005). Nevertheless, there is growing attention to patient-reported outcomes (PROs) as a valuable means of documenting the effectiveness of CAM vis-à-vis patients subjective experiences, their priorities, and the overall impacts on health, quality of life, and behavior change (FDA 2009). Given the fact that most CAM use is for health promotion (Davis, et al. 2011a), and that much of treatment-oriented CAM is aimed at chronic pain 5 and mood disorders 6 (Barnes, et al. 2008), PROs are likely better measures of the real world clinical goals of CAM therapies than are RCTs. Anthropologists (are involved in developing PRO measures that look beyond presenting symptoms and specific treatment objectives to capture multi-dimensional shifts in well-being following CAM therapies (Ritenbaugh, et al. under review; Thompson, et al. under review). 7 In addition to assessing treatment efficacy and effectiveness, there is a need to determine whether CAM therapies are cost-effective, as a means for justifying insurance coverage (Davis, et al. 2011b; Pelletier and Astin 2002). This suggests an important set of questions: What is the appropriate measure of the cost-effectiveness of CAM therapies? Fewer office visits? Less costly visits? Visits that address more concerns at one time? The long-term preventive effects of behavior changes catalyzed by CAM interventions? How does CAM use as a complement vs. alternative to conventional care impact its cost-effectiveness? Furthermore, because most insurance plans set limitations on the number of reimbursable CAM visits per year, there is a need for patient-centered research aimed at optimizing the relationship between the monetary costs and the therapeutic benefits (both specific and emergent) of CAM therapies. Specifically, how much CAM is needed to achieve and maximize therapeutic benefits? What are appropriate ways to discourage over-consumption of CAM (and conventional medicine) without impinging on therapeutic benefits? 3. Given the massive chronic disease/illness burden, what impact could CAM coverage have on public health priorities? Chronic disease, the number one cause of death and disability in the US (CDC 2010), amounted to $277 billion in treatment expenditures in 2003 (DeVol and Bedroussian 2007). Individuals with chronic disease are more likely to use CAM than those 5 Ndao-Brumblay et al. (2010) find high levels of CAM use among patients at a chronic pain clinic. Those using CAM for chronic pain tend to be younger, well-educated, white, and dissatisfied with conventional pain management. More research is needed to assess whether CAM use indicates delays in access to conventional care for pain management. Insurance coverage and cost of care may be limiting factors for CAM use among those with chronic pain. 6 Mood disorders, including depression and anxiety, are among the most prevalent chronic illnesses and among the most common reasons for CAM use among Americans. There is some evidence that CAM therapies including natural products, mind-body therapies, and acupuncture may be effective and cost-effective means of managing mood disorders (Moss, et al. 2011). 7 NIH/National Center for Complementary and Alternative Medicine, Developing Patient-centered Measures for Outcomes of CAM Therapies. R01AT (Cheryl Ritenbaugh, PI; Mark Nichter, Co-Investigator) [$675,000] 3

4 without chronic disease 8, and there is some evidence that it may also be cost-effective to cover CAM therapies or offer integrated CAM and biomedical care for chronic disease management (Herman, et al. 2005; Lind, et al. 2010; Lind, et al. 2007; Vos and Brennan 2010). Furthermore, although CAM users are more likely to have chronic illnesses, and more likely to report more doctor visits, ER visits, and days in bed, paradoxically, they were also more likely to self-report their health as excellent or to describe it as improving over the previous year (Nguyen, et al. 2011). Thus, CAM therapies may help individuals with chronic disease feel healthier and may improve health over time. This is a fruitful area for anthropological research. At the same time, there is a need for research assessing the role of CAM in promoting healthy behaviors and lifestyle choices for the prevention of chronic disease (Davis, et al. 2011b; Duncan, et al. 2011; Hawk, et al. 2011). Although large proportion of those using practitionerbased CAM therapies present with risk factors for chronic disease, including obesity, inactivity, smoking, hypertension, and diabetes or prediabetes (Hawk, et al. 2011), CAM users, in general, engage in more positive health behaviors and lifestyle choices than non-users (Nahin, et al. 2010). Considering the enhanced patient-provider relationship, longer appointments, and holistic, long-term approach to health and wellness at the heart of many CAM modalities, CAM providers may be particularly well-suited to encourage and support important shifts in behavior (e.g., diet, exercise, smoking cessation) and body awareness among their clients (Williams-Piehota, et al. 2011). Recognizing the potential role for CAM providers in catalyzing lifestyle and behavior change, anthropologists are involved in a project training CAM practitioners to integrate smoking cessation into their routine practice and to use brief motivational interviewing strategies to get patients to reconsider their smoking behaviors in relation to their current health problems and health goals. 9 Along these lines, there is need for assessment related to reimbursement of CAM providers for behavioral interventions: What structural limitations do CAM providers currently face with regard to reimbursement for services related to health promotion or disease prevention? What training, and/or specific interventions would allow CAM providers to qualify for reimbursement for behavioral counseling or intervention? 4. What are the effects of health insurance coverage on CAM providers and their practices? At the organizational level, greater inclusion of CAM in the current US health insurance system would affect shifts from self-governance among practitioners to governance by the system. Chiropractic medicine, the most widely covered CAM therapy, may provide a model for how CAM can be integrated into the existing health care system through a combination of patient demand and professional organization (Davis, et al. 2011b; Tillman 2002). This process would certainly involve increased regulation and standardization of training and practice, as well as increased requirements related to licensure, accreditation, malpractice, and so on. 10 In addition, it 8 An analysis of NHIS data (Saydah and Eberhardt 2006) indicates that individuals with arthritis (59.6%), cancer, lung disease or two or more chronic diseases (55%), and cardiovascular disease (46.4%) are more likely to report ever using CAM than those with no chronic diseases (43.6%). The exceptions are those with diabetes alone (41.4%). 9 NIH/NCI Tobacco Cessation Training for acupuncture, massage, and chiropractic practitioners, R01 CA AI (Myra Muramoto, PI; Mark Nichter, Co-Investigator), [$3,141,019] 10 Gilmour et al. (2011) consider the organizational challenges and liability concerns related to the integrating CAM care into institutional health care settings (hospitals/clinics). They argue that CAM therapies should be assessed and responded to (recommended, tolerated or discouraged) on the basis of safety and efficacy. Furthermore they offer several recommendations for setting out clear policies with regard to the credentialing of CAM providers, informed consent, standards of care, scope of therapy, referrals to conventional care, patient monitoring, product consultations, liability insurance, and the provision of cost information for patients. 4

5 would likely fuel the broadening of a CAM research industry aimed at producing evidence of efficacy, effectiveness, and cost-effectiveness. While many CAM providers will embrace formalized inclusion in the system, others will undoubtedly resist this process, due to concerns about increased external regulation and control over their practice, the increased burden and hassle of billing through insurance companies, and the affect of these processes on their relationships with patients. Studies of these processes and their effects on the professional identities and practices of CAM providers will be needed. Finally, although US health reform is intended to extend coverage to 30 million currently uninsured Americans, there will still be many who are un- or underinsured (the poor, homeless, undocumented, etc.). Anthropologists can play an important part in documenting the role of CAM in filling the gap for these individuals and families. 11 Can CAM play a role in primary care for these populations? Is it cost-effective? Will it improve outcomes? In sum, there is increasing evidence that complementary and alternative medicine may be ideally-suited to address key issues at the center of the US health care crisis by providing costeffective, patient-centered care that promotes health, helps to mitigate the symptoms of chronic illness, and catalyzes behavior and lifestyle changes to prevent chronic disease. Structural changes related to US health reform provide an opportunity to integrate CAM providers and CAM therapies more fully into US health insurance schemes. Anthropologists have a responsibility to help unpack questions related to the expansion of CAM coverage, the effectiveness and cost-effectiveness of CAM, the impacts of CAM on primary care and public health priorities. Acknowledgements: Preliminary work on this essay was supported by NIH/NCCAM Arizona Complementary and Alternative Medicine Research Training Program, T32 AT01287 (Iris Bell, PI), in which JJT was a predoctoral fellow and MN faculty. References Cited: 2010 The Patient Protection and Affordable Care Act. In Public Law United States of America: accessed 12/1/2011 at Barnes, PM, B Bloom, and R Nahin 2008 CDC National Health Statistics Report #12. Complementary and Alternative Medicine Use Among Adults and Children: United States, Bellas, A., et al Frequency, predictors, and expenditures for pediatric insurance claims for complementary and alternative medical professionals in Washington State. Arch Pediatr Adolesc Med 159(4): Breuner, Cora Collette, Paul J. Barry, and Kathi J. Kemper 1998 Alternative Medicine Use by Homeless Youth. Arch Pediatr Adolesc Med 152(11): Carter, Bernie 11 For example, in a survey of CAM use by homeless youth in Seattle, Breuner et al. (1998) found very high rates of CAM use among this population (70.1%). Referred by friends, and attracted to CAM because they view it as natural as well as affordable, effective, and caring, homeless youth may also view it as psychologically more accessible than biomedical care. 5

6 2003 Methodological issues and complementary therapies: researching intangibles? Complementary Therapies in Nursing and Midwifery 9(3): CDC 2010 CDC Chronic Disease Overview. Cleary-Guida, M. B., et al A regional survey of health insurance coverage for complementary and alternative medicine: current status and future ramifications. J Altern Complement Med 7(3): Davis, Matthew A., et al. 2011a Health Behaviors and Utilization among Users of Complementary and Alternative Medicine for Treatment versus Health Promotion. Health Services Research 46(5): Davis, Matthew A., James M. Whedon, and William B. Weeks 2011b Complementary and Alternative Medicine Practitioners and Accountable Care Organizations: The Train Is Leaving the Station. The Journal of Alternative and Complementary Medicine 17(8): DeVol, Ross, and Armen Bedroussian 2007 An Unhealthy America: The Economic Burden of Chronic Disease. Milken Institute. Duncan, A. D., et al Employee use and perceived benefit of a complementary and alternative medicine wellness clinic at a major military hospital: evaluation of a pilot program. J Altern Complement Med 17(9): Eisenberg, D. M., et al Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey. Ann Intern Med 135(5): FDA 2009 Guidance for industry: patient-reported outcome measures: use in medical product development to support labeling claims.. US Department of Helth and Human Services, ed. Washington, DC: UCM pdf -- accessed August 2, Gilmour, J., et al Hospitals and complementary and alternative medicine: managing responsibilities, risk, and potential liability. Pediatrics 128 Suppl 4:S Hawk, Cheryl, Harrison Ndetan, and Marion Willard Evans Jr 2011 Potential role of complementary and alternative health care providers in chronic disease prevention and health promotion: An analysis of National Health Interview Survey data. Preventive Medicine (In press; corrected proof available online). Herman, P. M., B. M. Craig, and O. Caspi 2005 Is complementary and alternative medicine (CAM) cost-effective? A systematic review. BMC Complement Altern Med 5:11. IOM 2005 Complementary and Alternative Medicine (CAM) in the United States. Washington DC: National Academies Press. Lafferty, W. E., et al. 6

7 2004 The use of complementary and alternative medical providers by insured cancer patients in Washington State. Cancer 100(7): Lafferty, W. E., et al Insurance coverage and subsequent utilization of complementary and alternative medicine providers. Am J Manag Care 12(7): Lind, B. K., et al Complementary and alternative provider use by insured patients with diabetes in Washington State. J Altern Complement Med 12(1):71-7. Lind, B. K., et al Comparison of health care expenditures among insured users and nonusers of complementary and alternative medicine in Washington State: a cost minimization analysis. J Altern Complement Med 16(4): Lind, B. K., et al Use of complementary and alternative medicine providers by fibromyalgia patients under insurance coverage. Arthritis Rheum 57(1):71-6. Moss, A. S., et al Complementary and alternative medicine therapies in mood disorders. Expert Rev Neurother 11(7): Nahin, Richard, et al Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, National health statistics reports 18. Nahin, Richard, James Dahlhamer, and Barbara Stussman 2010 Health need and the use of alternative medicine among adults who do not use conventional medicine. BMC Health Services Research 10(1):220. NCCAM 2011 What Is Complementary and Alternative Medicine? Ndao-Brumblay, S. K., and C. R. Green 2010 Predictors of complementary and alternative medicine use in chronic pain patients. Pain Med 11(1): Nguyen, L. T., et al Use of complementary and alternative medicine and self-rated health status: results from a national survey. J Gen Intern Med 26(4): Pelletier, K. R., and J. A. Astin 2002 Integration and reimbursement of complementary and alternative medicine by managed care and insurance providers: 2000 update and cohort analysis. Altern Ther Health Med 8(1):38-9, 42, 44 passim. Ritenbaugh, Cheryl, et al. accepted Developing a Patient-Centered Outcome Measure for Complementary and Alternative Medicine Therapies: I. Defining Content and Format. BMC Complement Altern Med. Rose, Nikolas 2001 The politics of life itself. Theory Culture & Society 18(6):1-+. Saydah, Sharon H., and Mark S. Eberhardt 2006 Use of Complementary and Alternative Medicine Among Adults with Chronic Diseases: United States The Journal of Alternative and Complementary Medicine 12(8):

8 Steyer, T. E., G. L. Freed, and P. M. Lantz 2002 Medicaid reimbursement for alternative therapies. Altern Ther Health Med 8(6):84-8. Thompson, Jennifer Jo, et al. accepted Developing a Patient-Centered Outcome Measure for Complementary and Alternative Medicine Therapies II: Demonstrating Content Validity through Cognitive Interviews. BMC Complement Altern Med. Tillman, Robert 2002 Paying for Alternative Medicine: The Role of Health Insurers. Annals of the American Academy of Political and Social Science 583(ArticleType: research-article / Issue Title: Global Perspectives on Complementary and Alternative Medicine / Full publication date: Sep., 2002 / Copyright 2002 American Academy of Political and Social Science): Verhoef, M. J., A. L. Casebeer, and R. J. Hilsden 2002 Assessing efficacy of complementary medicine: Adding qualitative research methods to the "gold standard". Journal of Alternative and Complementary Medicine 8(3): Verhoef, M. J., et al Complementary and alternative medicine whole systems research: Beyond identification of inadequacies of the RCT. Complementary Therapies In Medicine 13(3): Vos, Lynn, and Ross Brennan 2010 Complementary and alternative medicine: shaping a marketing research agenda. Marketing Intelligence & Planning 28(3):349. Williams-Piehota, P. A., et al Agents of change: how do complementary and alternative medicine providers play a role in health behavior change? Altern Ther Health Med 17(1):