Disruptive functional medicine innovation drives value-based future at Cleveland Clinic
April 5, 2017
By Taylor Walsh and Glenn Sabin Christensen, one of the nation’s leading authorities on disruptive innovation in business, wrote those words at a time after the early forces of healthcare disruption had started coalescing, around 2000. He would not have recognized them at that time because they were not dependent upon the technological advances he often cites as the basis for successful disruption. Rather they were, and remain, disruptive in how patients can be most beneficially treated. This evolution has often been painful, and it may yet produce profit, if, as we will see, that disruption establishes value based on quality outcomes, reduced costs and patient satisfaction. The Triple Aim by any name. Those early disruptive forces in care first stirred in the U.S. in the 1980’s, initially in the form of formal recognition of complementary and alternative medicine (CAM) modalities by the U.S. healthcare system. The subsequent growth of clinical businesses and their patient populations (to shocking levels by 1991²) was completely driven by patient preferences and out-of-pocket spending that was not reimbursable. Today, we know the care that has emerged during this evolution and its embrace by western medicine—integrating once unfamiliar modalities and views of health with medicine’s response to the preponderance of chronic illness and disease—as the proving grounds for integrative medicine (see the following notable examples). Since 2000, early variations of Christensen’s “focused-hospitals” arose within many traditional healthcare institutions and systems:
- In the establishment of many Centers of Integrative Medicine at U.S. medical schools, growing from eight at its 1999 inception to more than 70 today, and leading to the formation of The Academic Consortium for Integrative Medicine & Health, ACIMH.
- The growth of integrative health and medicine in the U.S. Military Health System and especially the VA that began in the wake of the wars in the Middle East, that now influences the approaches to care and healing in these and other major institutions.
- The investment in integrative medicine and health units at academic and non-academic regional and national hospital systems such as Mayo, Allina, Medstar, Sutter Health, Meridian Health and Beaumont Health (many, including the VA, are now members of ACIMH).
Ready, Set…Expand AgainSince opening in the fall of 2014, the CC-CFM has grown significantly: expanding its clinical space twice (to 18,000 sq. ft.); enlarging its practitioner staff; and establishing its initial research and data analysis operation. All of which has taken place while serving some 4,200 patients from 38 states and 12 countries, and building a word-of-mouth waiting list that stood at 3,000 in early 2017. Hyman noted that the clinic was designed to facilitate healthcare transformation not only through how care is provided, but how the transformation presents itself. This includes specially designed clinical space that attained a WELL Building certification, how the provider teams are organized around each patient, and functioning within the Cleveland Clinic as “a virus” by becoming part of its continuum of care across the institution. The challenge, as it remains for all hospitals, health systems, and academic centers offering mixed conventional and integrative services, is getting paid. Both Hanaway and Hyman had examples of the mismatch between the healing value of their work and the business value that remains to be established. For instance: Hyman described a 40-year old woman suffering arthritis, reflux, irritable bowel syndrome, migraines, depression, and pre-diabetes. Her multiple prescriptions included a drug costing $50,000/year, which she would likely depend on for many years in order to manage her condition. Hyman said his functional workup identified inflammation and conditions in the gut that he treated. After two months the patient’s symptoms were gone, she was off the meds, and she’d lost 20 pounds. By any measure a great outcome and real value to the patient and to the care system. But not to Cleveland Clinic because the downstream value of the treatment went unreimbursed; in other words, the savings to the system were not recognized. “We are not reimbursed for the value we’re providing,” he said. It is an achingly familiar refrain that can be heard across the now rapidly expanding integrative healthcare landscape. (And dealing with this reality is the subject of our preceding article, Institution-based Integrative Medicine: Current Economic Challenges and Opportunities.) Hyman calls this status, “Reimbursement No Man’s Land,” where volume still takes precedence over value. “We don’t have evidence-based healthcare,” he notes. “We have reimbursement-based healthcare.” In cases like the one Hyman described above, the Cleveland Clinic is filling the payment gap.
The MethodDr. Hanaway’s presentation described the programs and clinical systems, analytical tools, team-building and research programs being put in place to create this paradigm of value. These include:
- Conducting a select group of small RCTs.
- Working with the Institute for Functional Medicine to standardize clinical protocols.
- Collecting and integrating quality, outcome and cost data (often for the first time ever).
- Collecting patient case studies that illustrate the patient experience.
A “Total Cost of Care” TrialEven for this highly touted and innovative unit of the Cleveland Clinic, getting access to claims data was not straightforward. Hanaway reported that CC-CFM had to demonstrate the efficacy of its work and obtain IRB approval for the cost of care trial. Once established, this comparison looked at the number of specialty visits made within a year after an initial clinical encounter made by CC-CFM patients vs. the Clinic’s own standard-of-care patients. CC-CFM patients made two; propensity-matched control patients in the routine care cohort made five. RCTs are also being conducted in Type II Diabetes, and Asthma.
Outcomes: Function and CostIn assessing improved function and reduced symptoms, Hanaway noted the challenge this can present for measuring the progress made by patients who are treated for co-morbidities with whole-person approaches that characterize functional medicine. But by using the CG-CAPS patient satisfaction evaluation, he said, the CC-CFM “ranks in the 90th percentile in physician interaction and quality.” Another measure, using the NIH’s PROMIS-10 tool to compare the results of “clinically significant improvement” from CC-CFM treatments to those of the Clinic’s family medicine unit (CC-FM) (already among the nation’s best for patient clinical improvement), demonstrates the following improvement scores:
- CC-CFM: + 38.7 percent
- CC-FM: + 27.4 percent