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Aligning Incentives: The Project for Integrative Health and the Triple Aim
American Public Health AssociationIntegrative, Complementary and Traditional Health Practices Section
November 3, 2015
John WeeksPublisher-Editor, Integrator Blog News & Reports
Past Director, ACCAHC Center for Optimal Integration: Creating HealthProject for Integrative Health & the Triple Aim
Participants will be able to:
• Explain the challenges to optimal integrative care in production-focused payment and delivery
• Describe how opportunities are opening in the Triple Aim era.
• Discuss a project to support all stakeholders in creating the optimal use of IHM practices and professions.
Slides are available
Overview
Alignments of Interest/No Conflicts
Naïve Beginnings: “Hot-Tub Claims” of Integrative Health Practitioners
So, what is your value to your patients?
After my care, my patients:
• Can do more things• Aren’t in as much pain• Suffer fewer adverse effects• Have more energy• Enjoy things more• Feel better
4
Naïve Beginnings: Typical Hot-Tub Claims of Integrative Health Practitioners
So, what is your value to the system?
My services:
• Diminish use of pharmaceuticals
• Lower adverse effects of pharmaceuticals
• Limit needs for more expensive conventional tests and services
• Lower costs
5
Out of the ClosetUnconventional Medicine in the United States
Eisenberg, et al New England Journal of Medicine, January 28, 1993
Academic center for research team
• 34% of the population had used some “unconventional” treatment
• $13.8 billion spent, mainly out-of-pocket
• Little communication with conventional providers
____________________________
Impact was transformative:Market interest from hospitals, insurers, media, political figures
Individual activists empowered: I am not alone
Publication revealed breadth of the popular
movement
• Insurance: carved out and assumed an add-on
• Delivery: in separate integrative centers
• Delivery: valued for marketing not outcomes
• Research: Focused on mechanism not outcomes
• Economics: Low income, sustainability problems
Challenges for “CAM” Integration in the Production-Focused Medical Industry (1995-2010)
The original Integrator: 1997-2002 St. Anthony’s “The Business of
Integrating Complementary and Alternative Medicine” then 1998-2002
“The Integrator for the Business of Alternative Medicine”
Misalignment with the tertiary-oriented, procedure/income focus
Integrative health business models tend to fare poorly in the perverse incentives of a production-based
medical industry
Who wants Ornish’s program if it cuts down CABG, stents?How much “production” from a $65 massage? From self-
care? Changed life-style? Mindfulness?
The Question That Arose:IF there is Big Money in
integrative health and medicine, is it in saving money via
lowering costs?
NCCAM/NCCIH: Mandate to Answer Real World Questions
(c) COMPLEMENT TO CONVENTIONAL MEDICINE.—In carrying out subsection (a), the Director of the Center shall, as appropriate, study the integration of alternative treatment, diagnostic and prevention systems, modalities, and
disciplines with the practice of conventional medicine as a
complement to such medicine and into health care delivery systems in the
United States
Priorities(1) Outcomes research and
investigations.(2) Epidemiological studies.
(3) Health services research.(4) Basic science research.
(5) Clinical trials.(6) Other appropriate research and
investigational activities.
US Senator Tom Harkin:Prime Sponsor
Background: Cost/Quality Crisis in the Medical Industry
• 1965: Medicare/Medicaid established
• 1973: Congress passes HMO Act
• 1993: Clinton reform – like 1973, HMO focused
• 2010: Affordable Care Act – “HMO-light” with ACO, PCMH
Reform intention Shift payment incentives (FFS to health outcomes), whole
system thinking, production of services to the value of evidence
Cost/Quality Crisis & Response in the Medical Industry:Medical Errors & the Rise of “Values Based Medicine”
• 1987/1997: “Evidence-based medicine”– Eddy, Sacket
• 1999: IOM’s To Err is Human – Est. 100,000 deaths/year due to medical errors
• 2001: IOM’s Crossing the Quality Chasm
Where does this leave the USA?
• Almost 2X cost of any other high income nation• Lower life expectancy• Up to 440,000 deaths/yr. via error
Journal of Patient Safety September 2013 - Volume 9 - Issue 3 - p 122–128
Is it time to start a campaign against
“single payer deniers”
Side-Note: If science unanimously shows better outcomes at lower costs with a certain form of health care …
Shifting the “Perverse Incentives” in the Medical Industry
When else do we speak of perversity in our culture?
Rise of “Values Based Medicine”
The ValuesPatient-Centered, Outcomes, Silos to Teams,
Individuals to Community, Sick-Care to Health, Cost-reduction, Safety
• 2008: “Triple Aim”
• 2010: ACA & Accountable Care & PCMHs, bundled payment, etc.
Shifting Incentives
“When I first heard of integrative medicine in
2006, I thought of it as an expense …
Ken Paulus, CEO, Allina Health System
Weeks J. Health System & Military Leaders Say Cost and Pain are Motivating Inclusion of Integrative Medicine http://theintegratorblog.com/index.php?
option=com_content&task=view&id=795&Itemid=189
Ken Paulus, CEOAllina Health System
Shifting Incentives
“… but as the Affordable Care Act's payment structure
kicks in that supports keeping people healthy,
integrative medicine will be an asset.“
Ken Paulus, CEO, Allina Health System (2011)
Weeks J. Health System & Military Leaders Say Cost and Pain are Motivating Inclusion of Integrative Medicine http://theintegratorblog.com/index.php?
option=com_content&task=view&id=795&Itemid=189
Ken Paulus, CEOAllina Health System
Why an asset now??
Penny George Institute for Health and Healing/Allina
Focal Areas for Value Addition
• “Lower cost, raise quality”• “Primary cost element in hospitals is pain
management”• Lower pain, lower side-effects, lower
pharmaceutical use• Increase self care/self-efficacy/satisfaction• Resilience training/decrease depression• Diminish re-admissions
Lori Knutson, BSN, BC-HNPast-Director, Integrative Health Care
Penny George Institute/AllinaVia Interview, 11/27/11
Penny George Institute for Health and Healing/Allina
“If we show improvement in patient satisfaction, now key in Medicare - if we shake this score by one point - it
can mean a million dollars in additional payment to the system.”
_________“We know we’ll make a positive
impact. Now the hospital is paying all the costs for the program.”
Lori Knutson, BSN, BC-HNPast-Director, for Integrative Health Care
Penny George Institute/AllinaVia Interview, 11/27/11
Fairview: Incentives for IHM in ACOs/PCMHs
“Integrative medicine supports self-efficacy.”
“We have good evidence that some integrative therapies help a patient’s
ability to cope.”
“Many of today’s costs are associated with a lack of a holistic, integrated
approach”
“The movement is toward more holistic measurements of health and well-being”
Dave Moen, MD, Executive Medical DirectorFairview Health Services
Fairview: The Shifting Value of Integrative Services
“A provider’s value used to be associated with
what you bill in fee-for-service. Now it is all about
the outcome of your care.”
Integrator interview: November 28, 2011. Search Moen at www.theintegratorblog.com
Dave Moen, MD, Executive Medical DirectorFairview Health Services
University of Minnesota Health System
Healthpoint: Integrative Care in a “Patient-centered healthcare home”
“When economics are organized around producing healthy people,
what any practitioner needs to do is look at what gives us the effect that
we are trying to cause. And that is, to have a healthier population.”
Note: Healthpoint’s (12 FQHCs) have had naturopathic doctors, acupuncturists, nutritionists, massage, and groups for 15 years.
Healthpoint's Tom Trompeter: Integrative Medicine in a Patient-Centered Healthcare Home http://
theintegratorblog.com/index.php?option=com_content&task=view&id=792&Itemid=189
Tom Trompeter, MPA, CEO, Healthpoint12 FQHCs, 465 employees, $40-million budget
King County Washington
Healthpoint: Integrative Care in a Community Center Model
“Break the paradigm of a physician owning a patient.”
“Team approach opens the door for
diversity. There’s no cookbook.”
“My patient needs to transition to our patient.”
“It’s not about the billable visit.“
Healthpoint's Tom Trompeter: Integrative Medicine in a Patient-Centered Healthcare Home http://
theintegratorblog.com/index.php?option=com_content&task=view&id=792&Itemid=189
Tom Trompeter, MPA, CEOHealthpoint
King County Washington
Alignment in the Community: Triple Aim Values & Integrative Health and Medicine Leader Perceptions
Leaders of Licensed IHM Professions (DC, AOM, ND, Massage, Direct-Entry Midwifery)
91% Aligned (47% “perfectly”)Source: Academic Consortium for Complementary and Alternative Health Care Biennial Meeting Survey 2013
Academic Integrative Medicine Center Leaders
90% Aligned (43% “strongly”)Source: Project for Integrative Health and the Triple Aim 2014
Perceptions of Medical Delivery Organization-Based Integrative Center Directors
on Any Changes in the Values-Based Medicine Era
Testing the “Paulus Hypothesis” Has the ACO/PCMH Era Opened New Opportunities?
Purpose Examine perception/experience of health system-based center leaders as to whether opportunity is increasing in the new “values-based” environment
SurveyedLeaders of integrative centers in academic medicine and health systems – the “Bravewell” list
SponsorACCAHC via PIHTA, with $$ from the Leo Guthman Fund
Team John Weeks, ACCAHC, Center for Optimal IntegrationJennifer Olejownik, PhD, ACCAHC, PIHTAMelinda Ring, MD, Osher Center at NorthwesternJeffrey Dusek, PhD, Penny George Institute/Allina Health
Target: Leaders of the 28 Clinics in the 2012 Report- 75% Response Rate (21)
Valued as Asset -- Hospital Readmissions
Statement: “With changes in payment and other incentives, my center/clinic is increasingly part of the system’s plan to lower hospital readmissions.”
Strongly Agree
Agree Somewhat Agree
Neither Agree orDisagree
Somewhat Disagree
Disagree Strongly Disagree
10 19 48 10 10 5 0
Statement: “With changes in payment and other incentives, my system leaders increasingly view IHM as an asset in meeting new goals.”
Strongly Agree
Agree Somewhat Agree
Neither Agree orDisagree
Somewhat Disagree
Disagree Strongly Disagree
14 5 52 14 0 14 0
Better Patient Experience -- Lower Costs of Care
Statement: “With changes in payment and other incentives, my center/clinic is increasingly part of the system’s plan to reduce cost of health care.”
Strongly Agree
Agree Somewhat Agree
Neither Agree orDisagree
Somewhat Disagree
Disagree Strongly Disagree
19 38 29 10 0 5 0
Statement: “With changes in payment and other incentives, my center/clinic is increasingly part of the system’s plan to better patient experience.”
Strongly Agree
Agree Somewhat Agree
Neither Agree orDisagree
Somewhat Disagree
Disagree Strongly Disagree
5 29 38 24 0 5 0
Is the System Investing More?
Strongly Agree
Agree Somewhat Agree
Neither Agree orDisagree
Somewhat Disagree
Disagree Strongly Disagree
5 24 10 29 14 10 5
Statement: “Due to these changes in payment and other incentives, my organization-center has experienced an increase of financial investment of the system in our service offerings.”
Note all that apply to your center/organization as a result THE CHANGING HEALTHCARE LANDSCAPE
Statement N Percentage
Our personnel have been asked onto new committees and initiatives related to these changes
12 57.10%
We are actively working with new specialty groups 14 66.70%
We experience increased interest in involvement of our services and providers in inpatient services
12 57.10%
We have internal evidence that we are helping the system reach one or more goals of the Triple Aim objectives.
9 42.90%
We have published evidence in peer-reviewed literature that we are helping meet one or more of the Triple Aim objectives
1 4.80%
We are on the public record in other media that we are helping meet one or more of the Triple Aim objectives.
5 23.80%
We are engaged in efforts of our specialists and provider groups to lower-per-capita costs
6 28.60%
Our clinic has become a PCMH 1 4.80%
We are actively applying for Patient Centered Medical Home Status 3 14.30%
We are exploring our potential relationship to the Patient Centered Medical Home model
8 38.10%
Inclusion in the A.C.A.
Section Title Area Language Used
2706 Non-Discrimination Payment “ …license or certification …”
3502 Community Health Teams/Patient-
Centered Medical Homes
Delivery “doctors of chiropractic, licensed CAM practitioners …”
4001 National Prevention, Health
Promotion and Public Health
Council
Health promotion
“integrative health care” “integrative health care strategy” “integrative health” “integrative health
practitioners” “integrative health practices”
5101 National Health Care Work Force
Commission
Workforce “doctors of chiropractic”“licensed CAM providers, integrative health
practitioners”
6301 PCORI-CER Research “experts in integrative health and primary prevention strategies” “State-licensed integrative
health care practitioner”
Plus, growing interest of the military chiropractic/integrative health practices & practitioners
Making the Cost & Quality Case for Exploration and
Inclusion
Some Steps Taken
• WIN: Samueli Institute’s Wellness Initiative for the Nation (2008)– Informed development of the
National Prevention, Health Promotion and Public Health Institute
• Bravewell Collaborative: The Efficacy and Cost-Effectiveness of Integrative Medicine (2012)
Other Resources on Cost .
IM leaders from academic medical centers
Wayne Jonas, MD, CEO
Cost-Effectiveness in 28 Studies (2012)
• General: BMJ Open publishes a report with evidence of cost effectiveness in 28 high-quality studies (Herman, Eisenberg-2012)
• General: Often much higher satisfaction and “self-efficacy” outcomes with CAM practitioners and integrative treatment
Source: Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations
RAND’s Patricia Herman, ND, PhD: economist,
researcher
Harvard’s David Eisenberg, MDBMJ Open 2012;2:e001046 doi:10.1136/bmjopen-2012-001046
"I'm tired of this talk that there is no evidence for cost-
effectiveness of complementary and integrative medicine. There is evidence. We need to move
onto phase two and look at how transferable these findings are. We can take this evidence
and run.“
Patricia Herman, ND, PhDRAND Corporation
“There is evidence …”
Patricia Herman, ND, PhD
Herman quoted in : J Weeks , “Review Finds Cost Effectiveness of Complementary and Integrative Medicine in More Than Two Dozen High-Quality Studies.” The Huffington Post, September 27, 2012.
Integrative Health Policy Consortium (2015)
Integrative Heath and Medicine: Today’s Answer to Affordable Health Care
Health Creation Economics
Other Resources on Cost .
Erica Oberg, ND, MPH, Mimi Guarneri, MD, Patricia Herman, ND, PhD
http://accahc.orghttp://centerforoptimalintegration.org
Core Professions in ACCAHC
*Only schools accredited via the Commission on Massage Therapy Accreditation. There are over 1300 schools.Source: Clinicians and Educators Desk Reference on the Licensed Complementary and Alternative Healthcare Professions. ACCAHC. Goldblatt, Weeks, Rosenthal et al. 2nd Edition, 2013.
Profession Accrediting Agency
Established
US Department of
EducationRecognition
RecognizedSchools or Programs
Standardized National Exam
Created
StateRegulation*
LicensedPractitioners
Acupuncture & OrientalMedicine
1982 1990 61 1982 46 27,000
Chiropractic 1971 1974 15 1963 50 72,000
Massage Therapy
1982 2002 88* 1994 44 280,000
Direct-Entry Midwifery
1990s 2001 10 1994 26 2000
Naturopathic Medicine
1978 1987 7 1986 16 5500
Core Member Organizations
Create the connective tissue
Collaborate &Engage
-Data-Best practices-Webinars-News pushes-Face-to-face
www.optimalintegration.org
An Initiative to Support the Emerging Era
• Hospital Transition• Integrative pain treatment• Chronic disease• Patient self-efficacy• ‘Dual eligible’• Care management• Pharmacy management• … and more
PIHTA Adviser Karen Milgate: Some High Value Areas for Engagement
.
Opportunities exist – how do we step up?
Karen Milgate, MPPFormer Deputy Director, CMS;
Advisory Team, PIHTA
Goal: Assist All Stakeholders in Fostering Optimal IHM Integration
PIHTA was funded together through small
investments from:
Visual Outcomes, CHP Group, Leo S. Guthman
Fund, Westreich Foundation, NCCAOM, NABNE & Casey Health
Institute
Additional PIHTA ContentExamples of IHM Integration into PCMHs/FQHCs For example: • Casey Health Institute (Maryland)• Clinix Healing Center (Colorado)• Lane County Health Center (Oregon)• Naturopathic doctor-led PCMHs (Oregon, Vermont)• Venice Family Clinic (California)• Healthpoint (Washington)• Webinar with 3 leaders
Studies on Patient-Experience of IHM• Peer-Reviewed, Published Studies with Patient Self-Reports • Third Party Instruments from Health System and Employers • Reports and Papers from Integrative Organizations and Institutions • Webinar with Beryl Institute• Other Useful Papers and Studies
Coming: Workplace Clinics, Credentialing, Competencies• Cisco, Google, Honeywell International, plus• Basic information on credentialing/privileging• Content to support development for competencies in integrated
environments
PIHTA Investors
PIHTA Investors and Project Partners – 2013-2015Jennifer Olejownik, PhD, Project Manager
Leo S. Guthman Fund
VisualOutcomes
• Allina estimates $2000 savings per in-patient via integrative care program– Lori Knutson, RN, BC-HN, speaking to
Natural Medicine Journal
• Duke integrative wellness program (Prospective Health) estimates $2200 savings per client– Ralph Snyderman, MD
JAMA. 2010;303(4):363-364
Some Evidence for the Cost Case
Hospitals & Health Systems
• Ford Motor Company acupuncture trial lowers medication use 58%– Kenneth R. Pelletier, PhD, MD (hc) et al,
same outcomes Journal of Occupational and Environmental Medicine as An Integrative Medicine Intervention in a Ford Motor Company Assembly Plant.
• Canada Post whole practice naturopathic medicine lowers CV risk, saves $1021 year– Dugald Seely, ND, Patricia Herman, ND, PhD
Some Evidence for the Cost Case
Employers
• Access DC first saves with LBP– 20%-40% lower cost if see DC first for LBP– Blue Cross Blue Shield Tennessee (Finch,
Goertz, others)
• Cost of insureds using CAM disciplines < those not using CAM– $1420 LESS in those with large dz. Burden,
$140 MORE in those with less dz. burden– Washington state (Lind, Lafferty)
• Medical Expenditures Panel Survey re back pain– CAM users $526 less cost on back care,
$726 less overall
Some Evidence for the Cost Case
Insurers & 3rd Party Payers
Relaxation Response Program: Effect on Health Services Utilization (2015)
Harvard Benson-Henry Institute TeamRelaxation Response Resiliency Program (3RP)
4000 patients compared to a usual care cohort.
“At one year, total utilization for the intervention group
decreased by 43%
• clinical encounters decreased by 41.9%• imaging by 50.3%• lab encounters by 43.5%• procedures by 21.4%.
Reduction of costs at $2360 per patient per year
Conclusion: “Mind body medicine interventions are inexpensive relative to the cost of an emergency room visit, a hospitalization or even other complementary and alternative medicine (CAM) therapies.”“Relaxation Response and Resiliency Training and Its Effect on Healthcare Resource Utilization.”http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0140212
Where does this leave us in 2015?
Increasing Radicalism Language/Focus in Academic Medicine
“I’ve spent 40 years tinkering with health
professions education and the tinkering has done
nothing. We need a transformation. And
transformational change requires death and
rebirth.”
Malcolm Cox, MDCo-Chair, IOM Global Forum on
Innovation in Health Professional Education
Retired Director, VHA Academic Programs
Increasing Radicalism of Language/Focus in Academic Medicine
“We are preparing people literally for a system that does not exist. We can’t just reform and tinker around the edges.
We need to break some boxes. We need to break the box of
the curriculum.” Susan Scrimshaw, PhDCo-Chair, IOM Global Forum on Innovation
in Health Professional Education,President, Sage College
Increasing Radicalism in Language/Focus in Medical Delivery Industry
“ … the new way, the way to health, may be vastly further from the current design of care than we may at first wish it to be, or believe it to be …
“The pursuit of health, the creation of health, may require something even bolder [than the Triple Aim]. The redesign we need may be even more radical than we have imagined."
Donald Berwick, MDFormer CMS Administrator,Founder, Institute for Health
Improvement
Increasing Radicalism in Language/Focus in the Medical Delivery Industry
“We have been honed to focus on sick care … It is a tough transition, but we
have to learn how to move from sick care to health
care. I'm not sure that any of us fully understands or
knows the recipe."
Jonathan Perlin, MD, PhDChair-Elect, AHA
CEO, HCA
Medical Industry(Medical Delivery Organization)
Sick Care (System)
System of Health Creation(Health care system)
Language for Transformation
Alignment: Health Professionals in the 21st Century Need to Be “Change Agents”
Type of Learning
Objectives Outcome
Flexner/1910
InformativeInformation,
skillsExperts
Post WWII-1950
FormativeSocialization,
valuesProfessionals
Today/2010
TransformativeLeadership attributes
Change agents
The Source: Health Professionals for a New Century: Transforming education to strengthen health systems in an interdependent world. The Lancet (2010)
How Do We Lead? Two Fellowships and a Leadership Program
New Interprofessional Fellowship
First Significant Fellowship
What Role(s) for the IHM Community?
Thank You!
John WeeksPublisher-Editor
Integrator Blog News & Reportswww.theintegratorblog
206-851-1758
