PolicyAMA’s $70 million CPT royalty reported, attacked as subsidy for subjugating other disciplinesA recent report in the Integrator revealed that the political work of the American Medical Association (AMA) is subsidized to the tune of roughly $70 million each year
AMA’s $70-million CPT royalty reported, attacked as subsidy for subjugating other disciplines
A recent report in the Integrator revealed that the political work of the American Medical Association (AMA) is subsidized to the tune of roughly $70-million each year through royalties from its ownership of Current Procedural Technology codes (CPT). Providers from all disciplines who accept 3rd party payment effectively pay into this AMA fund, despite the fact that the AMA opposes the advances of other disciplines, especially as independent practitioners. The Integrator report was prompted by concerns of integrative nursing leader Mary Jo Kreitzer, RN, PhD on learning that the AMA had immediately opposed the independent practice for nurses recommended in the long-awaited October 5, 2010 Institute of Medicine (IOM) report entitled The Future of Nursing: Leading Change, Advancing Health. A multidisciplinary IOM team presented the vision of a future in which nurses, without MD supervision, will provide a significant portion of the nation’s primary care. Nursing supporters welcomed the study as opening a “golden age of nursing.” The AMA immediately opposed this core recommendation.
The AMA position continues that of the 2006-present AMA Scope of Practice Partnership (SOPP) campaign through which the AMA supports opposition to scope expansions of other professions, including chiropractic doctors, midwives (nurse and direct-entry), psychologists, naturopathic physicians, optometrists, acupuncture and Oriental medicine practitioners as well as advance practice nurses. The AMA also opposes the anti-discrimination portion (Section 2706) of the Obama reform law. The AMA’s control of the CPT also gives this guild the right to keep other disciplines from developing proper codes for their field. In addition, the AMA’s CPT ownership gives the guild a special relationship to the US government relative to payment policy.
Comment: It is an astonishing confrontation with the past to imagine that such power was ever conferred on a single guild. The necessary transformation of US healthcare is toward diversity, multidisciplinary practice, collaboration, team-care, and respect for the skills of all parties. The movement is away from the still current MD-centric, patriarchal, top-down, father-knows-best world of Dr. Kildare. The response to the Integrator article has been, bluntly put, that enough is enough. (See 18 Views: Forum on the AMA’s $70-million CPT Warchest Includes Calls for Action to End the Subsidy.) Says integrative nurse Kreitzer: “Let’s end it.
The October 26, 2010 story in the Wall Street Journal is entitled Physician Panel Prescribes the Fees Paid by Medicare. It begins this way:
“Three times a year, 29 doctors gather around a table in a hotel meeting room. Their job is an unusual one: divvying up billions of Medicare dollars. The group, convened by the American Medical Association, has no official government standing. Members are mostly selected by medical-specialty trade groups. Anyone who attends its meetings must sign a confidentiality agreement.”
The WSJ article is based on work at the Center for Public Integrity. The article refers to the AMA’s panel, the Relative Value Update Committee (RUC), as “secretive” and to the group’s power as “enormous.” The Centers for Medicare and Medicaid Services typically follow 90% of the RUC recommendations. The panel is viewed as hampering reform efforts. A key area: resistance to moving resources toward generalists and primary care. Says former CMS administrator Tom Scully of the AMA’s role: “It’s indefensible. It’s not healthy to have the interested party essentially driving the decision-making process.”
Comment: Anyone wonder whether these old structures – CPT and RUC – might be getting in the way of reform? These two stories, both published October 26, 2010, are quite a pairing. The best comment on both is this reflection, relative to the CPT issue, from Lori Knutson, RN, BS-HN, director of integrative health care for Allina Hospitals & Clinics and the Penny George Institute for Health and Healing. Knutson writes here:
“Kudo’s for bringing awareness to the presenting problem of the AMA/CPT code ‘energy block’ that has somehow covertly managed to stay quite hidden in the meridians of our dis-eased healthcare system. Our ability to move this very important work forward does, at times, require exposing and experiencing the hidden devices of underlying cause. Sometimes debriding is the right medicine. I am sure that as the uprooting of our healthcare system unfolds there will be more surprises (learning’s?). Hopefully we have come to a point in our society that we realize its time to come together, let go, and remember ‘We the People’ created this and ‘We the People’ are obligated to make it right for the whole.”
The now year-long process of public commentary and response on the development of the 2011-2015 strategic plan of the NIH National Center for Complementary and Alternative Medicine recently stimulated a new round of responses from key stakeholders. Published here are letters from the American Association of Acupuncture and Oriental Medicine, Council for Responsible Nutrition, Academic Consortium for Complementary and Alternative Health Care and the Naturopathic Physicians Research Institute. A perspective of David Forbes, MD, president of the American Holistic Medical Association is here. The most significant common response is to honor NCCAM for prioritization of “real world research” and the health-promoting outcomes of integrative interventions, but also to urge that this focus be elevated. Disclosure: I was involved in drafting the ACCAHC letter.
The Integrated Healthcare Policy Consortium, directed by Janet Kahn, PhD, has moved forward in two areas since the September 27-29, 2010 policy conference on strategy to follow-up on the advances that “integrative practices,” “integrative practitioners” and “licensed complementary and alternative medicine providers” gained in the Patient Protection and Affordable health Care Act (PPACA). The conference was co-hosted by IHPC, Palmer College of Chiropractic and the Institute for Integrative Health. IHPC engaged leaders of a Health Resources Services Administration committee on shortage areas to educate them about the integrative practice fields, especially to provide information about disciplines that are considered part of the primary care matrix in some states, but are not typically included in federal programs. A focus in the IHPC’s October 4, 2010 letter was inclusion by the states of Vermont and Washington of certified professional midwives and naturopathic physicians.
In addition, IHPC, working with recommendations made by a conference work group on the Patient Centered Outcomes Research Institute (PCORI) and others, nominated three researchers for the PCORI Methodology Committee. Among PCORI’s charges are exploring integrative practices and including integrative practitioners in their leadership. Nominations were closed October 31, 2010. In between these activities, Daniel Redwood, DC and Kahn are working on the report from the conference. The Integrator will alert you when that is available.
Gladys T McGarey, MD is known to many as a founder of holistic medicine. In recent years, she has twice convened gatherings of holistic medical leaders, through the Gladys Taylor McGarey Medical Foundation, to explore strategies to shift the paradigm of US medicine. The 2010 report is based on 2 days of work by a selected group of 60 “holistic physicians, nurses, medical researchers and other integrative providers.” The recommendations in the report range from promoting wellness, supporting holistic pregnancy and birth, standardizing certification and licensing, and funding education and research strategies. The recommendations covered a broad arena, from changing conventional medical education to increasing research and practice and providing support for distinct fields such as naturopathic and homeopathic medicine. One unusual recommendation: “Recognizing Women as Important Healthcare Decision Makers.” The report notes that women are estimated to make 80% of healthcare decisions.
McGarey, energetic at 90-years-old, is making a series of visits to healthcare leaders in the Beltway in an attempt to foster the shift for which she has worked for decades. The reports from the 2009 Gathering of Eagles as well as those from the June 2010 meeting are anchored to President Obama’s call for reform. One target: educating administrator Donald Berwick, MD and the Centers for Medicare and Medicaid Services about the value of integrative approaches.
Comment: A colleague from a decade ago, Terry Schmidt, DHA, linked me into the work of McGarey’s team. McGarey’s energy is enviable. I urged her team to appreciate that some terrific coalition work is underway -especially that noted above through the Integrated Healthcare Policy Consortium, Samueli Institute, The Institute for Integrative Health and the Palmer Center for Chiropractic Research. Hopefully McGarey’s eagles will find ways to have their work dovetail with that of these organizations so power can begin to coalesce and who knows, perhaps prove effective!
Maine’s True North Healing Center recently sent out a press release following coverage of the clinic’s method of care in an article entitled Medicine without Doctors in Wall Street Journal’s SmartMoney. Rather than merely boasting the coverage, True North used the moment to describe the chasm between the media presentation which had left some false impressions and what actually takes place in True North’s integrative practice. For starters, the clinic boast both medical and naturopathic medical doctors. The release also educates about the functional medicine approach that both use, and the science behind Peggy Huddleston’s Prepare for Surgery, Heal Fast Program. In the account by the WSJ writer, “alternative medicine” was first discounted then the author chose to focus on a specific agent, a “bacteria-filled supplement supplied by the center.”
Comment: Funny, the WSJ writer started her “alternative medicine” bit that featured True North with 4 sentences discounting any evidence for such care, then proceeded to write an article which apparently was not evidence-based journalism. Credit True North for taking the lemons and making lemonade.
The Bravewell Collaborative of philanthropists for integrative medicine has published a new 16-page pamphlet entitled The Efficacy and Cost-Effectiveness of Integrative Medicine: A Review of the Medical Literature. The authors are: Ermenia (Mimi) Guarneri, MD, Scripps Center for Integrative Medicine, Scripps Health; Bonnie J Horrigan, Bravewell’s director of communications and public education; and Constance M Pechura, PhD, executive director of the Treatment Research Institute (TRI). The authors begin by indicating that
“A review of the medical, corporate and payer literature reveals that, to start, immediate and significant health benefits and cost savings could be realized throughout our health care system by utilizing three integrative strategies:
Integrative lifestyle change programs for those with chronic disease;
Integrative interventions for people experiencing depression; and
Integrative preventive strategies to support wellness in all.”
Comment: This pamphlet is a conservative presentation of the economic value of “integrative medicine.” The authors focus on the work of Dean Ornish in reversing atherosclerosis, mind body stress reduction programs of Jon Kabat-Zinn with depression, and corporate wellness programs. Not included are most of the studies referenced by economist-researcher Patrica Herman, MD, ND, PhD in her Systematic Review Yields Top 9 Therapies/21 Conditions with High Quality Evidence of Cost Savings from CAM . Not mentioned anywhere in the Bravewell presentation are any outcomes relative to practices by practitioners of massage, acupuncture, chiropractic, yoga therapy, naturopathic medicine or dietary supplements. (See, for instance: Analysis of Washington insurer data finds CAM-using insureds have lower expenditures than non-users.) Still, this little booklet, downloadable here, should prove useful in some environments.
“Health and wellness coaching is the change agent that shifts the culture and delivery of health care from dependency to empowerment.” So reads an aspirational poster from one of the working groups at the late September summit to explore national standards and certification in the field of health and wellness coaching. In an October 20, 2010 release from the organizers, Pamela Peeke, MD, an adviser to US Surgeon General Regina Benjamin, MD, MPH is quoted as saying: “Health and wellness coaches will play an integral role in the prevention portion of healthcare reform legislation – they will help catalyze a transformation in healthcare.”
The chairs of the meeting were Margaret Moore, co-director of Harvard’s Institute of Coaching and CEO of Wellcoaches Corporation, and long-time integrative and holistic medicine leader Karen Lawson, MD, director of health coaching at the University of Minnesota Center for Spirituality and Healing. A multidisciplinary group of 70 individuals attended. An issue that prompted the organizers is that “presently ‘health coach’ and ‘wellness coach’ can be used by anyone, whether or not they have completed coach training designed for health and wellness coaches.” In addition, training programs that exist are of varying lengths. An organizing team is expected to continue taking steps toward the inter-related goals of setting standards, creating credentialing and building a professional organization. A report from attendee Jennifer Johnson, ND is here.
Comment: Coaching, different than “education” or “counseling,” deserves an elevated role in integrative practice. I shared my views on this subject in With Standards in the Works, Is it Time to Claim, and Certify, the Health Coach Within? My perspective is not unanimously embraced. (See Chris Johnson, ND: “Disturbed” by the Positive View of Health Coaching in Integrative Practice.) Still, I believe that all integrative practitioners who claim that they help empower people have skin in this game.
On October 8, 2010, the National Certification Board for Therapeutic Massage & Bodywork (NCBTMB) announced “continued progress” in developing its exam for the National Certification for Advanced Practice (NCAP). NCBTMB presents the initiative as “the first to enable accomplished (massage) practitioners to differentiate themselves in the massage marketplace.” The agency suggest that the certification will also “make it possible for employers and members of the conventional and integrative healthcare arenas to hire practitioners based on a certified, advanced level of experience and expertise.” “NCBTMB Chair Neal Delaporta is quoted saying that “the credential will open up new opportunities for therapists in conventional, integrative and clinical healthcare settings. It has the potential to take the entire profession to a new level within the medical community.”
Comment: The idea of advanced certification has been floating around the massage community for some time. I asked 2 massage educator colleagues from the Academic Consortium for Complementary and Alternative Health Care (ACCAHC) for their perspectives. Jan Schwartz, MA, past chair of the Commission on Massage Therapy Accreditation, and an Integrator adviser writes:
“An advanced certification is needed in massage so that the public can tell the difference between therapists, but the question is how is ‘advanced’ defined? For example, I went to a school that had 1000 hours of education. NCBTMB requires 500 hours of education to take the current certification exam. So does that make me advanced before I even start? (The answer is no. I was told my education was entry level).
“I would have preferred to see exams that were more population-based (for the lack of a better term) in terms of techniques, knowledge, critical thinking skills, etc. For example, oncology massage requires more than what people get in massage school. Injury rehab and management requires more than what people get in massage school. Same with pregnancy massage. If I understand the new exam correctly, and Whitney (Lowe, LMT) can correct me if I’m wrong, this is a generalized advanced certification (and I don’t know what that means).
“Also the survey that goes out for the job task analysis will probably go to therapists who primarily graduated from 500 hour schools. How does that say what is needed for an advanced certification? I’m simplifying here, because others will no doubt complete the survey too, but you get the idea. I think they jumped into this without doing enough of the foundational work, but I could be wrong about that too.”
Schwartz’ colleague, author-educator Whitney Lowe, LMT, sent this additional e-note:
“I would concur with everything Jan has said here. I was on the task force that was working on this exam for a short time, but I resigned in protest due to the way in which I felt they were rushing the exam development process and not addressing key psychometric issues.
“The problem stems from an attempt to address a key need in our field (the ability to distinguish a massage therapist with basic knowledge from one with more advanced skills).
“[The offering] is also influenced by the
“However, it is also unfortunately influenced by the NCBTMB’s need for this exam to generate significant revenue because they are losing their primary revenue stream with their existing entry-level credential. This has led to a number of serious errors (which Jan has mentioned) in the exam development process and subsequently this also threatens the validity of the exam. (Another issue is that many in our profession don’t understand basic principles of psychometric validity so they don’t see the disconnect behind these concerns.)”
The loss of income to which Lowe refers is that a new Federation of State Massage Therapy Boards was created recently and offers an exam that is increasingly supplanting NCBTMB’s certification as a route to licensing.
The American Chiropractic Association (ACA) is one of several content partners participating in Sharecare, a new internet site created by entrepreneur Jeff Arnold together with Harpo Studios, HSW International, Sony Pictures Television and Discovery Communications and Mehmet Oz, MD. Arnold is credited as the originator of WebMD. A release from that ACA states:
“From ACA to the American Red Cross, the American Diabetes Association, John’s Hopkins Medicine, and others, Sharecare is bringing together the top minds in health care to provide consumers with multiple perspectives within a single Web site dedicated to improving health. The site will arm patients with more information about their health care options and empower them to make better choices.”
Sharecare is a new social media platform “designed to greatly simplify the search for quality health care information.” The ACA is a partner for chiropractic content. Donna Hill Howes, Sharecare’s senior vice president calls the partnership “a natural fit,” adding: “By bringing together the full spectrum of health care disciplines on an expert social QA platform to facilitate conversations about health, Sharecare is creating an environment that will foster innovation within the health care community. We are thrilled to feature the chiropractic profession’s perspective on health and wellness.”
Comment: Sharecare is an “internet play” with a world-wide vision and mission and with apparently some significant financial backing. Howes, for instance, is a former deputy director of a Bill and Melida gates Foundation unit involved with global health campaigns. In the business press Arnold is described as “the latest entrepreneur to test the potential of social networking.” AOL founder Steve Case’s Revolution Health is noted as a recent expensive failure. This is one to watch. The ACA has little risk.
Redwood’s piece focuses on “putting the integrity into integration”
In a commentary in the premier issue of the peer-reviewed Focus on Integrative Health Care, educator and writer Daniel Redwood, DC, lays out a case for his belief that “sustainable integrative health care systems must identify and nurture beliefs and behaviors that model health-affirming ideals, including patient-centeredness, openness, pluralism, holism, preventive self-care, harmony of action and belief, and minimalism.” Redwood’s piece is called Walking Our Talk: Putting the Integrity into Integration.
Redwood’s perspective draws from principles for integrative medicine lined out by Centers for Medicare and Medicaid Services administrator Donald Berwick, MD. He also highlights the “4 Pillars (Integrative collaborative care; Cultural competence; Clinical sensitivity; Technological innovation) and 2 Guideposts (Increased services to the underserved; Decrease the brain drain of healthcare professionals)” offered by integrative medicine clinician, policy activist and educator Len Wisneski, MD. Also cited by Redwood are some principles for health care renewal developed in 2001 and cited in the report of the White House Commission on CAM Policy.
Comment: Taking principles for granted is a dangerous business. Principles need tending, particularly if such tender shoots are to survive in the getting-and-spending, rough-and-tumble of capitalistic health care in the United States. My close colleague Pamela Snider, ND calls this tending “operationalizing the soul” of one’s medicine/health care. Good for Redwood to focus in on this intersection of principles and for Focus editor Cheryl Hawk, DC, PhD to highlight this topic in the journal’s premier edition.
The immensely successful liberal-left Huffington Post has chosen to give more presence to its medicine and health content by moving it out of the “Living” section into its own space. The content is overseen by a Medical Review Board replete with integrative medicine leaders. Dean Ornish, MD serves as medical editor and homeopath, acupuncturist and nutritionist Patricia Fitzgerald, DHM, LAc, CCN serves as “wellness editor.” HuffPo boast over 40-million unique visitors per month. The site’s editorial line promotes integrative medicine.
Side-note: Ornish’s bio states that he holds the Safeway Chair at Preventive Medicine Research Institute. Safeway has been a leader in corporate wellness modeling. Ornish and Safeway struck up a multifaceted relationship in 2005. (Thanks to Integrator adviser Jan Schwartz, MA for tipping me to the HuffPo story.)
A recent study in the Annals of Internal Medicine is leading some to question the findings of a large body of scientific literature. The reason is captured in the title of a related Los Angeles Times article: A placebo is a placebo is a placebo .. or maybe not, a new study suggests. Noted as an example is the use of a lactose pill as a placebo in a large trial which, due to the lactose intolerance in many people, is not inert. Thus, by potentially worsening the symportoms of those on “placebo,” to tested agent could be read as more positive than it is. The conclusions may have over-stated the drug’s value compared to what was clearly an uncontrolled control. The original Annals article is entitled What’s in Placebos? Who knows? Analysis of Randomized-Controlled Trials. The authors discovered that only 8% of studies with pills disclosed the nature of placebos (26% for injections). They recommended a policy of full disclosure.
Comment: The issue is of particular interest to the integrative practice fields given that not at all inert “placebos” have been used as “sham” acupuncture and manipulation – with outcomes that too often hit the media as “no better than placebo” when both treatment and placebo may be better than customary care.
Integrative attorney Michael Cohen joins California law firm
Integrative care author and attorney Michael Cohen has joined the Fenton Nelson healthcare law practice in Los Angeles. Cohen writes that he has “joined a stellar Los Angeles-based healthcare firm and am continuing to represent CAM providers and entities within a sophisticated, national health law practice.” Cohen, formerly part of the integrative medicine team at Harvard University, and most recently located in the Bahamas, has written over 100 books and papers on the maturing field. He continues to author the CAMLawBlog. A review of Cohen’s Healing at the Borderland of Science and Religion is here in the Integrator.
Charles C. DuBois, president of Standard Process Inc., was honored with an award from the Foundation for Chiropractic Progress for his dedication to chiropractic profession. Kent S. Greenawalt, chairman and founder of the Foundation stated: “Charlie and Standard Process are truly dedicated to helping the Foundation generate positive press for the chiropractic profession.” Through Standard Process, DuBois committed more than $3 million to the chiropractic profession in 2009. DuBois also serves as a board member for the Foundation. Standard Process was recently recognized as Wisconsin’s 63rd largest firm.
Management consultant Chris Ellis has taken over as executive director of the American Association for Acupuncture and Oriental Medicine (AAAOM). According to a notice from AAOM, Ellis “has worked closely with over fifty organizations in both the for-profit and non-profit sectors, helping them to improve their performance and value delivery.” Ellis authored The Enlightened Enterprise: Walking the Path of the Conscious and High Performing Organization, in which he “applies principles from Asian philosophical traditions to create a conceptual blueprint for the high performing enterprise of the future.” Ellis takes over for Rebekah Christensen who was honored by the AAAOM for her role in “helping to facilitate the AAOM/Alliance merger and led our profession into anew era of collaboration.” Ellis begins in a difficult moment for the organization, which has struggled to gather membership from the nation’s licensed acupuncturists.
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Knutson in new role as Allina Hospitals & Clinics expands integrative healthcare
Lori Knutson, RN, BS-HN, executive director for the Penny George Institute for Health and Healing at Allina Hospitals & Clinics notes that she has “officially transitioned my role to lead the Allina-wide Integrative Health Clinical Service Line as we are officially moving this work across Allina.” The move is significant as Allina has 12 hospitals in its system, plus an array of clinics and other facilities. Adds Knutson: “We open our comprehensive integrative oncology center in November and I am now working on a Whole Family Integrative Health Clinic in partnership with Minnesota Children’s Hospitals & Clinics IM group” led by Timothy Culbert, MD.
Shelly Johnson, deputy director of the American Massage Therapy Association (AMTA) for 8 years, was appointed AMTA’s interim executive director in August 2010. Johnson has worked with associations for 22 years, including the American Society for Quality, the American Society of Neuroscience, the American Board of Neuroscience Nursing, the Neuroscience Nursing Foundation and the American Society for Healthcare Materials Management of the American Hospital Association. Johnson replaces former executive Elizabeth Lucas in the position.
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