Integrating Integrative Medicine
By Laurie Larson
A How -- To Guide
The American Hospital Association’s 2003 Annual Survey of Hospitals showed that the number of hospitals offering integrative medicine, more commonly referred to as complementary and alternative medicine (CAM), doubled from 8 percent in 1998 to more than 16 percent in 2002. Among 1,007 respondents, 269 hospitals stated that they offered some CAM services. Their top three reasons for doing so were: patient demand (83 percent); organizational mission (69 percent); and clinical effectiveness (61 percent). Among hospitals not currently offering CAM, 24 percent stated that they planned to do so in the future. Should that percentage include your hospital? Maybe so—and it may be easier than you think.
You don’t have to commit to a new facility or even a new wing to offer integrative medicine, according to Donald Novey, M.D., medical director of Advocate Medical Group’s Center for Complementary Medicine in Park Ridge, Ill. Novey says success boils down to creating a good fit with a hospital’s existing clinical services, combined with a smart business plan and choosing the right CAM model. Novey defines five possible models: consultatory, virtual, primary care, fitness and spa.
The consultatory model employs CAM practitioners who treat patients by referral from a primary care or specialty physician. That physician continues to oversee the patient’s ongoing care. A variation, the focused consultatory model, targets CAM treatment to help patients with a specific condition such as heart disease. The virtual model comprises CAM services that are scattered throughout a hospital or system and are loosely coordinated. This model is the most common and the easiest to implement, used in about 75 percent of hospitals that offer CAM, Novey estimates. He describes the model as “almost a no-brainer,” since it can be offered without committing to a fully integrated approach, using existing staff. For example, physical therapists often know various types of therapeutic bodywork, and staff psychologists could likely provide guided imagery therapies.
The primary care model offers traditional medical care and CAM services together but is not commonly used, Novey says, because it is often perceived as competing with allopathic care. The fitness center and spa models cater to a wellness-oriented and often younger patient population. Both are expensive to implement, but fitness centers are more easily set up and understood, and can funnel users into other integrative services, such as nutritional counseling and smoking cessation. Spa models “really take hospitals into the catering and hotel industry,” Novey says, are usually paid for out-of-pocket and define themselves as a “resting place” with CAM services such as massage and yoga. Based on his experience and the extensive advice he has given to others, Novey suggests the following eight-step process to bring integrative medicine in-house.
Step 1: Choose the Right Model
Choosing the right model means research: conducting surveys to learn what services the community wants, examining service population demographics, and finding out what the competition is doing so you don’t copy them, Novey advises. In addition, a medical staff survey will reveal physicians’ interest in and knowledge of CAM, which, in turn, will inform the integrative business plan on the number of likely referrals.
Step 2: Have a Viable Business Plan
First and foremost, the mainstays of whichever integrative therapy(s) are offered should be reimbursable, Novey advises. Although the 2003 AHA survey found that the majority of patients pay for CAM services out of pocket, the most frequently reimbursed services included: nutritional counseling (56 percent); biofeedback (54 percent) and chiropractic (49 percent).
In Novey’s experience, the five most commonly reimbursed CAM services, beyond physicians’ consult exams are: manipulative medicine, such as chiropractic; massage therapy and other types of therapeutic bodywork; acupuncture; mind-body medicine, including counseling and stress reduction; and nutritional services. He calls these “anchor” or “float” services, meaning that they provide economic stability and keep the center financially afloat. “Make sure one of these five will pay the bills,” he says. Other CAM therapies not typically covered might include aromatherapy, reflexology, ayurvedic medicine, reiki and other types of therapeutic touch. “As an integrative medicine person, you have to think like a medical and a business person,” Novey says. “The right business plan begins with finding the indicators of viability.” This means asking:
• Do we have an “anchor” service or services, i.e., one that will definitely be reimbursed? Novey says that each state varies on what services it covers, as does each insurance carrier. Research what your state reimburses.
• Will the hospital administration and board commit to at least three to five years to show a return on investment (ROI)? The ROI should have annual revenue projections and a clear course of action for correcting them if they turn out to be wrong, Novey says. However, he adds that, “if nothing good is happening in 18 months, [executive leadership] may close the center in two years—they get nervous after 18 months.”
• Do we have realistic assumptions about projected revenues, based on prevailing fee scales and the demographics of the service population? Expectations on predicted revenues should be realistic. “Don’t fudge, or overestimate profits,” Novey warns. “It’s better to be too modest than overly optimistic.” As a rule of thumb for what fees to charge, he suggests 75 percent of the range of average charges in the market.
• Do we have a plan for controlling overhead? Novey cautions against overbuilding, and advises boards and administrators to keep overhead and staff costs low. “It’s more important to stay alive than to have a beautiful hardwood floor facility,” he says. Office space should be modest, making use of spare rooms within the hospital or physician offices, if possible, as his center has done, rather than building new. For the most part, all practitioners in a CAM program should be independent contractors rather than salaried staff.
To gain needed support from executive leaders and the board, Novey thinks CAM champions need to be able to tell them what CAM can do. “[CAM] will expand market share and increase [the hospital’s] service radius by offering a subspecialty service, since such services are not typically available,” he says. “When done correctly, the image of the hospital will go up.”
Step 3: Avoid Bear Traps
Novey defines “bear traps” as “problems that will pop up if you don’t assume they are there and plan for them.” Not being able to prove financial viability to the board and hospital administration early on is a prime example of a bear trap, Novey says, as is planning that results in excess overhead. The biggest bear trap, however, may be the medical staff hostility that can result if physicians don’t know CAM providers and don’t trust the way they work. The best way to plan for this type of bear trap is to educate those you hope will refer patients to the service. Without that education, you will never reach the next step.
Step 4: Link to an Existing Referral Base
“A physician will never refer to someone he doesn’t understand,” Novey says. “Physicians must really know these [CAM practitioners], as well as the reasons to refer to them, the indications for using their services.” Novey stresses that referrals should be two-way, i.e., directing patients, when appropriate, back to traditional medicine from CAM. This gives tremendous credibility to integrative medicine once traditional doctors realize that CAM is not purely a “lure” away from allopathic care.
“When you refer out of integrative care, it [makes] a powerful statement and gives 75 percent of all the reassurance you need to doctors,” Novey says. Such two-way referral must also be accompanied by strict follow-up, including consult letters and accurate charting.
Step 5: Choose the Right People
Just as important as deciding what therapies to offer is hiring the best practitioners to provide them. To find the right staff, CAM champions should make sure all their practitioners have appropriate national and state credentialing, and should conduct a criminal background check. Additionally, Novey says he always asks for skills credentialing—requesting that CAM job candidates demonstrate their proficiency by giving a massage or an acupuncture treatment, for example, to a staff member.
Step 6: Build a Team
Novey emphasizes the importance of “fit” or philosophic agreement between practitioners about how they want to practice integrative care and how they want to work together, as well as how they hope to work with allopathic physicians.
Novey believes the team approach his center takes to integrative medicine is the key to its success. “The team approach is the philosophic core,” Novey explains. Twice weekly, all center CAM providers hold a mandatory meeting to discuss current cases and brainstorm suggested treatments. Participating therapists include a massage and therapeutic bodywork practitioner, a chiropractor, a homeopath, a clinical therapist, a nutritionist, an acupuncturist, a Chinese herbalist and Novey.
“Complementary and alternative providers may not know how to work in groups,” Novey explains. “They tend to be lone wolves … when we sit around the table and review cases, saying ‘Here’s how I see the world,’ it’s mind-expanding for everyone.” Next, through interaction with traditional providers, CAM providers learn how they think and work, and physicians learn about CAM. These consults produce what Novey calls “super practitioners” who know how to chart correctly as well as how to cross refer to allopathic physicians and other CAM professionals.
Step 7: Make It Safe
The team meetings are also part of what Novey describes as a “web of checks and balances” between integrative and allopathic medicine, tracing the “pathway of risk.” The first risk begins with the first contact, so the front office staff needs a “script” to make sure they get a complete medical history and fully document all complaints. Novey says it is also vital that CAM professionals follow through with consult letters, describing what treatments they are providing or intending to provide to a physician’s patients, ensuring that all chart data are current.
Step 8: Send the Right Signal
CAM champions should remember that traditional physicians’ skepticism about their work comes from their protectiveness toward their patients, Novey says. “Doctors hold the ideal for their patients, they want what’s best for them. Once they are not worried, they are interested.” That’s why Novey believes that physician education on proposed CAM services should grow simultaneously with the development of those services. The right presentation by the right person—preferably a physician champion who can speak clinicians’ language—is crucial because without referrals, a CAM center’s success will be doubtful. What physicians are looking for, in a nutshell, is the evidence-based case for integrative medicine. “If you can give a good lecture, concerns evaporate,” Novey says. In the end, he thinks those physicians who express the strongest concerns about CAM can become the best insurance that treatments are safe.
Interventional cardiologist Erminia Guarneri, M.D., co-founder and medical director of The Scripps Center for Integrative Medicine in San Diego, believes a great CAM program begins with “a physician leader who is passionate about doing this work.” She advises using that champion’s specialty as the place to introduce integrative therapies, exactly as cardiology was the launching specialty for her center. “You always have to have a figurehead,” Novey says, and he could be describing Guarneri—or himself. The “point person” or director for any integrative service or center needs to wear multiple hats, he says, acting as the liaison between administration and the board, the medical staff, patients and the public, and will most likely be a physician or a nurse. The suggested medical staff survey, sent as part of the initial needs assessment, serves the dual purpose of finding out which physicians are likely to refer to CAM services, as well as learning who might be the best choice to lead the CAM program.
Ultimately, both Novey and Guarneri see CAM, if properly implemented, as part of best practices for all care. “We should get away from the terms ‘alternative,’ ‘complementary’ and ‘integrative,’” Guarneri says. “If the modalities work, it just becomes medicine.” She adds, “When you see the change in patients, you are transformed yourself. I could never turn backº to just using stents and drugs now. I need all these things for my patients.”
Laurie Larson is Trustee’s associate editor.
This article 1st appeared in the December 2099 issue of Trustee Magazine.
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