Complementary and Alternative Medicine
By Laurie Larson
A consumer CAM-paign
From acute to rehabilitative care, and particularly with chronic health conditions, providers are learning that complementary and alternative medicine (CAM) offers many simpler, less invasive and often less expensive ways for patients to repair and improve their health than allopathic (i.e., traditional) medicine. But perhaps the bigger news is that their patients are way ahead of them. Consumers are investigating CAM therapies in increasing numbers—and seeking treatment at the hospitals that offer it.
More than 25 percent of hospitals surveyed last December by the American Hospital Association’s Health Forum subsidiary said they offered one or more CAM therapies, most often in response to patient demand.
“People are voting with their feet—they want [CAM] integrated as part of the medical world,” says Karen Fulton, director of health promotion at Borgess Medical Center in Kalamazoo, Mich., and head of its integrative medicine department.
Hospitals in the Health Forum survey also cited CAM’s clinical effectiveness, the desire to attract new patients and differentiate themselves in the market, as well as a goal to treat “the whole person” as reasons they have expanded into CAM, also sometimes called integrative medicine. Typical CAM therapies include acupuncture, chiropractic, reiki, homeopathy, herbal medicine, hypnosis, biofeedback, massage therapy, stress management and diet changes, among others.
National statistics have shown that for every one out of three Americans who say they have used CAM treatments, 84 percent say they would do so again. Additional data from Alternative Medicine Online show that, as far back as 1991, Americans made 425 million visits to CAM providers, compared with 388 million visits to traditional providers, spending $13.7 billion on CAM, 75 percent of which was out-of-pocket.
“I predict that if public and private hospitals take on what consumers want, what is efficacious, what makes them feel better, [those hospitals] will thrive,” says Merrily Manthey, executive director of the Foundation for Excellence in Health Care in Kent, Wash. “Hospitals can provide true leadership and facilitate the ‘thrive-al’ [i.e., thriving survival] of themselves by promoting the best of both [allopathic and CAM] worlds.”
Manthey has been in private practice as a psychotherapist for 35 years, specializing in stress management, biofeedback and alternative therapies. She also served on the board of Harborview Medical Center in Seattle from 1990 to 2000. She says that, at her suggestion, Harborview’s medical director convened a task force in 1994 to analyze various CAM therapies in use at the medical center, including mind-body interactions, diet and nutrition, hypnosis and acupuncture. Its goal was to examine these modalities to see if there was enough scientific evidence of their efficacy to discuss them more often with patients as treatment options.
At the same time, surveys were given to all medical and clinical staff, as well as patients, to gauge their opinions and knowledge of CAM. Any future integrative therapy offerings would thereafter be judged not only on their scientific efficacy and safety, but also on clinicians’ willingness to accept them and incorporate them into standard care plans, as well as the likelihood of significant patient demand. The task force concluded that existing practices would be expanded after learning that more than half of Harborview patients surveyed said they already used alternative treatments.
“CAM has so much to do with balance and meaning,” says Donald Novey, M.D., medical director of Advocate Medical Group’s Center for Complementary Medicine in Park Ridge, Ill. “Real integrative medicine understands that all therapies are not for everyone. It has to do with the physical nature of the individual.”
Approximately a third of his patients are referred by physicians, nurses and physical therapists, frequently from within the Advocate system, and the other two-thirds are self-referred for complaints ranging from headaches and back pain to allergies, asthma, arthritis and digestive problems as well as therapies that complement cancer treatment.
Therapies offered at the center include massage and therapeutic body work, chiropractic, homeopathy, nutritional counseling, acupuncture, Chinese herb therapies and mind-body medicine— all prescribed following an integrative medicine evaluation.
“Where we excel is with chronic headaches, back and neck pain—some [patients] never go to physical therapy because we take care of it,” Novey says. “And we also look at lifestyle and emotions—that’s why CAM is so powerful.”
Although most services require patients to pay out of pocket, the exception is chiropractic care, which is widely covered by insurance. “Reimbursement shapes the whole thing … and Medicare shapes coverage for those over age 65,” Novey says. However, word of mouth is not to be underestimated. “Once a patient likes a CAM referral, it happens more often,” he adds.
Kathleen Yosko, president and CEO of Marianjoy Rehabilitation Hospital in Wheaton, Ill., agrees with Novey that her hospital’s best marketers are its patients, but Marianjoy has also established a referral network of more than 100 acute care physicians and nurses who coordinate their discharge planning with them.
“There are lots of [insurance] pressures to move patients out of the hospital,” Yosko says. “Our nurses and doctors talk to discharge planners and social workers about Marianjoy as a transition out of acute care—there’s a solid relationship now.”
CAM’s Role in Rehab
Yosko says CAM therapies make sense in rehabilitative medicine, a specialty that has itself evolved from a series of different therapies complementary to all other disciplines. “It’s an applied science rather than a pure science, and it’s always been that way,” she explains. Marianjoy’s 120-bed facility offers rehabilitation for patients who have suffered brain injury, stroke, spinal cord injury, orthopedic or musculoskeletal injury or have neuromuscular disorders. The facility also offers pediatric rehab and a pain management program.
Adjunct CAM therapies include acupuncture, biofeedback, massage therapy, reiki, therapeutic touch and aromatherapy. The latter can be useful for patients with brain injuries—the scent of vanilla, for example, is such a familiar smell for most people that it often helps the brain reorient itself, assisting coma patients in returning to consciousness. “If you can find simple ways to calm patients or stimulate them other than pharmacology, use them,” Yosko recommends.
The hospital is currently building a new facility, scheduled to open this month, with the same number of beds, but now in private rooms only. Built on a 60-acre wooded campus, the new hospital will include an outdoor labyrinth for meditative walking, an “enabling” garden (where patients will garden as therapy) and a meditation room. Even though consumer demand has definitely shaped the new construction—Yosko has seen a steadily growing consumer interest in CAM over the 36 years she has been a nurse and a hospital administrator—she adds that, “I’ve always believed that the whole process of rehabilitation is naturally holistic—we don’t just treat the injury or disability, we treat the whole person.”
At Kalamazoo’s Borgess Medical Center, CAM therapies are offered at its Health and Fitness Center, which combines medical services with a community fitness facility. Although the center began by offering only massage in the fitness center eight years ago, “patients asked for more,” Fulton says, and now, along with physical, occupational and recreational therapy, Borgess offers acupuncture, hypnotherapy, naturopathy and colon hydrotherapy, in what Fulton describes as a “multidisciplinary approach,” working with its affiliated medical staff.
“Providers wanted to refer [to us] for integrative therapies, but they wanted to feel good about the credentials [of therapists], and they wanted good communication,” Fulton says, to ensure that their traditional care was blending well with CAM. She says her staff has worked hard to assure physicians in their ambulatory care center that patients would get CAM services “complementary to primary and acute care, but not competitive with it.”
Still, 80 percent of patients self-refer to the center, Fulton says, and although some payers reimburse for some services, or for only a certain number of visits, patients pay for services up front and then work on reimbursement with their payers after treatment.
“Some patients want help with something that primary care doesn’t help or that they wouldn’t go to primary care for, such as acupuncture or to see a naturopath,” Fulton says. “It’s anecdotal, but in many patient surveys, they say this is the only place that has solved their problem.” She says she has seen attitudes toward CAM change considerably over the past few years.
“I’ve been with Borgess for 20 years and the shift I’ve seen—with more evidence-based studies and greater consumer demand—the integrative therapy world has done a better (i.e., improved) job of talking to the medical world about what’s happening [in CAM treatment] so it doesn’t seem like ‘voodoo medicine,’” Fulton says. “There’s been education on both sides … and that is the key … it has to go both ways for there to be crossover.”
Acupuncture and the Physician
Perhaps one of the most dramatic areas where that crossover is occurring can be seen in the numbers of physicians who are seeking acupuncture certification, such as David Bilstrom, M.D., medical director of the Complementary Medicine Center within the Advocate Good Samaritan Health and Wellness Center in Downers Grove, Ill. The 5-year-old center offers massage, chiropractic, biofeedback, herbal medicine, cranial-sacral therapy, yoga, tai chi, meditation and acupuncture, and practitioners regularly interact with physical, occupational and speech therapists.
Bilstrom is a physiatrist, a physician who specializes in rehabilitative medicine. Five years into his practice, he became certified as an acupuncturist to aid his work with spinal cord patients.
“Spinal cord care is complex and some of these [patients] are limited on their medication options—the side effects become bad,” Bilstrom explains. Spasticity, bladder and bowel problems, pain and other side effects can flare up just as medications are gradually “ramping up” to their effective dosage. Or, side effects may develop over time, so patients can’t continue to use medications even though they still need them. “I thought, ‘There’s got to be something to help people that doesn’t have side effects,’” Bilstrom says. “Acupuncture kept popping up—it has no side effects, no interactions with other medications—it’s much more effective than I ever thought it would be.”
It has now become a “first-line intervention” early on in spinal cord treatment, Bilstrom says. Not only does acupuncture relieve pain immediately, patients stay well after acupuncture treatments stop, he says, unlike Western medications, which must be regularly taken to maintain their benefits. Bilstrom uses acupuncture in conjunction with physical therapy and other traditional rehab therapies, primarily in outpatient treatment, and he has also started a combined inpatient/outpatient acupuncture program at Advocate-affiliated Christ Hospital in Oak Lawn, Ill. In both the hospital’s rehab and acute care units, he sees patients who have had acute strokes and multiple sclerosis exacerbations. The brain typically works to heal itself during the first three months following a stroke and then stops, Bilstrom explains. However, he has found that if acupuncture is given to patients immediately following a stroke, the brain continues to heal for much longer.
Although such demonstrated benefits should be impressive enough in themselves, allopathic medicine has been slow to accept the notion of the “energy channels” through which acupuncture needles do their work, since they don’t correspond to observable nerve or lymphatic channels, Bilstrom says. Recently, however, science has found ways to trace the tiny electrical charges that acupuncture needles produce and transmit through the body’s connective tissue, or “fascial planes”—sheets and bands that connect muscle groups—or “the path of least resistance” as Bilstrom describes it.
“Our technology is starting to catch up to our experience,” he explains. Now, 90 percent of his patients are referred by physicians. “They refer to me because they know me—and often because patients ask for it,” Bilstrom says. He currently sees 100 patients a week for acupuncture, often using it as “a springboard” to help them feel well enough to benefit from physical therapy that was previously too painful.
CAM Champion
To assist in building understanding and referrals between allopathic and integrative medicine—and to send the message that CAM is valid—Manthey suggests creating a CAM coordinator position within the hospital. This could be an outside hire or an employee with an informed interest in CAM, such as a physical or occupational therapist, or a nurse.
The coordinator, as well as other staff and volunteers, would receive initial training in whatever CAM therapies the hospital decides to use, and the coordinator would then be the point person for “starting the process of familiarizing all departments with CAM options,” Manthey says. Bodywork is a simple way to begin, she suggests, such as introducing massage after hip surgery to reduce the amount of pain medications patients need.
“It is important that whoever leads a CAM department understands how to connect CAM people and concepts to those in the [traditional] medical field,” Fulton adds. The coordinator is “a huge hinge to make this happen. There can’t be two circles that don’t cross over. You need someone comfortable in both worlds who can connect them both.” She agrees that nurses are naturals to fill this role but adds that a CAM coordinator’s “characteristics as a leader are more important than credentials—having a business sense and good one-on-one skills—that’s what’s most important.”
What can the board do to start such changes in motion? Manthey recommends that hospital leaders who want to integrate CAM into hospital treatment protocols should begin by looking at which of their services are the most expensive and/or the least reimbursed, ascertaining what cost-effective, evidence-based CAM treatments could be added on or used to replace them.
Harborview’s classic case is the now-standard provision of vitamins C and E to surgical patients in the ICU to prevent organ failure. (See “Amazing CAM Therapies,” this page.) “You don’t need at $50 pill if you can get a 5-cent dose of vitamin C,” Manthey says.
Alternatively, health care leaders could work in the opposite direction—finding the least expensive, yet effective alternative to an existing service—“rather than the latest and greatest new [technical] toy,” Manthey says. Homeopathy and acupuncture might be alternatives or adjuncts to drugs or surgery, as broad examples.
Manthey further recommends that trustees and hospital leadership do as Harborview did and “engage a deliberative, motivated internal task force,” to survey patient CAM use, looking at existing hospital practices and opportunities for integration. Consultants could be brought in to fast-track the process and help choose a demonstration project, either in a clinic or in a particular area of the hospital. Finally, Manthey recommends an ongoing program of CAM education for senior leadership.
“There is no time for looking in the rearview mirror … looking forward is the only option for survival,” Manthey states. “Trustees must educate themselves and set new goals to meet their mission. They must stand in support of cultural change so that the physicians who see the benefit of integrative medicine will feel free to bring innovation to the institution.” In her opinion, learning more about integrative therapies is more of a mandate for survival than simply a good idea.
“The health care system has got to adopt these therapies or they will close their doors—costs will eat them up,” Manthey asserts. A large part of those costs are pharmaceuticals, not only in terms of actual cost, but also expensive in their interactions with other drugs and with the body over time, adding another level of complexity to care. “You treat one condition [with a drug] and you get three other chronic problems,” Manthey says. “If we don’t get at the root cause [of illness] we will create more stress on our ability to provide care. We have to look at how to provide [CAM] services or patients will find [their own] alternatives.”
Laurie Larson is Trustee’s senior editor.
This article 1st appeared in the December 2099 issue of Trustee Magazine.
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