Integrative Medicine Clinical Leaders on Policy Priorities: Bland, Gahles, Hui, Kligler, Luck, Hudson, Warner and Jones
Clinicians of all sorts prefer focusing on their patients to thinking about policy or worse yet, participating in policy change activities. This may be particularly true of integrative practitioners. One encounters various levels of discomfort, unfamiliarity, uncertainty and pessimism about the value of engagement. Ironically, these feelings often co-exist with strong views about what is wrong or what should be done differently, an urgent sense of a need for transformation, and wishful thinking toward different healthcare policies.At the 2013 Integrative Healthcare Symposium for which I serve as an adviser, I button-holed a set of eight presenter-clinicians whose lives are principally located in work with patients or thinking about clinical issues. The group included 4 women, 4 men: a PhD, 4 MDs, a chiropractor homeopath, a naturopathic doctor and a nurse coach. I posed this question to them:
Consider the 1000 attendees, almost entirely clinicians, in the plenary of an Integrative Healthcare Symposium audience. The main subgroup is MDs, plus large subsets of nurses, naturopathic doctors, chiropractic doctors, health coaches and others. If you were to give them your recommendation of the top policy or policy-related issue with which to be engaged, what would it be?
Some were surprised by being put on this spot and requested some orienteering. Many made it clear that this is not their expertise. Others were closer to organizational activity of various sorts that overlap into policy issues. Here are their wonderfully diverse responses. I close with some summary comments.Follow-up: You might try answering this question yourself before reading.
1. Jeff Bland, PhD: Legislated mandates for payment for collaborative and prospective servicesJeff Bland, PhD, is the founder of the Institute for Functional Medicine and a regular keynoter at the IHS gatherings. He is currently focusing on his new direction, the Personalized Lifestyle Medicine Institute. I connected with Bland just after his opening keynote and following a brief exchange about certain seniors taking up paddle-board surfing.Bland: "Until we find a way to incent practitioner to work collaboratively, prospectively and preventively, we won't stop the rising ocean of end-stage diseases. We'll never roll it back. There has to be a legislative mandate to support providers to engage in personalized, preventive clinical activity. Practitioners won't do it in the absence of a change in the way people are reimbursed. It would be wonderful if one state stepped forward, like with cannabis, and modeled this and collected the right data that would be irrefutable."2. Wendy Warner, MD, ABIHM: "We need to get together and have the same message"Wendy Warner, MD, ABIHM is an integrative medicine doctor who is the founder and director of Medicine in Balance, a holistic practice outside Philadelphia. She is a former leader of the American Board of Integrative Holistic Medicine. She was one of the four medical doctors invited onto the Dr. Oz show in when he featured functional medicine. I caught up with her on the exhibit floor.Warner: "The first and foremost thing is that we all need to get together and have the same message. There are factions. We need to get together and identify our message. How often can you get the response you want if you don‘t have the same message? I am still not sure that we are actually an integrative medicine community. Even inside the MD and DO integrative communities we need to get the holistic and integrative and functional medicine doctors and the academic integrative medicine doctors together and decide what is our message. Then we need to get together with all the others to get clear on what is our message."I told Warner she was the queen of the moment. So what did she think that message should be? She responded:Warner: "We need to go back to basics. We need to change the way we relate to food. We need to change how we handle stress. It's the big picture stuff. That's where we'd have to go with our message."3. Nancy Gahles, DC, CCH, RSHom(NA): "Implementing the non-discrimination clause" Nancy Gahles, DC, CCH, RSHom(NA) is a chiropractor from New Jersey who, following lengthy study of homeopathy became involved in the National Center for Homeopathy (NCH) for which she served as president. She recently limited her clinical practice. She is presently an outlier in this group as she is retained part-time as a policy-consultant to the NCH for which she served on the board of directors of the Integrative Healthcare Policy Consortium with which I have been involved. I popped the question after breakfast the last day.Gahles: "I am heavily involved with the Integrative Healthcare Policy Consortium in implementing the non-discrimination clause, Section 2706, of the Affordable Care Act. This is work at the state level. If we want people to have a choice, if the community wants people to have access to integrative practitioners, this is very important. Most people use insurance for what they choose in health care. Section 2706 will allow them to have an insurance policy that includes licensed integrative healthcare providers by allowing them to be covered. This won't be easy. Getting the interpretation we want will be a dance. The insurers will want to keep them out. Providers need to get involved with their state associations. [In IHPC] we're figuring out how to work on this best with Deborah Senn, the former Washington State insurance commissioner. Get involved. This is a big opportunity to change things. Contact your state association. Have them contact IHPC."4. Ben Kligler, MD, MPH: "Gather the cost data in our practices to make the cost case"The vice chair of the department of integrative medicine at Beth Israel hospital, Ben Kligler, MD, MPH is a clinician at the Continuum Center for Health and Healing. He has been a leading educator in integrative academic medicine since work in the late 1990s with the Society of Teachers of Family Medicine. He is the current chair of the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM). We spoke after a panel I moderated on which Kligler served in which had a robust dialogue with the audience on the potential for integrative health and medicine in the shifted payment incentives of accountable care organizations (ACOs). Kligler: "I think as practitioners we need to be engaged in ways to gather the cost data about your own practice or in networks with others. Cost is such a driver of thinking about healthcare choices. This is what I feel I have to be doing. It's not the most interesting work to me. I'm interested in people's care and how I can improve it. But I am beginning to think we can't make the change we want in people's care if we can't make this case. I think that as a clinician community we have abdicated concern about costs and just said we should be able to do whatever we want for our patients. It's got us into trouble. We need to figure out how to make the case on costs."I asked Kligler what the leading policy issues for CAHCIM are:Kligler: "Of course, policy is not our focus. But we put a lot of energy recently into informing our members of the importance of what's in essential health benefits and we put out the word about the non-discrimination section  so they could be active if they wanted."5. Susan Luck, RN, BS, MS, HNC, CCN: "Think more about families and communities"A regular presenter on holistic nursing topics is Susan Luck, RN, BS, MS, HNC, CCN. Most recently, Luck has been promoting the elevation of the health coaching role in nursing practice, most significantly through her co-founding of the Integrative Nurse Coach Certificate Program. I pulled her away from another meeting for a brief interview.Luck: "We need to begin to think more about the community and a more expanding vision. We need to be thinking more about the community health model, and then about the service component in it. What should integrative practitioners do in the best community health model? I was struck by a story Mary Jo Kreitzer described of nurses in the Netherlands who got together and went out as a group into their communities. We need to take the message of empowering people out to communities. They often don't need a doctor. They need coaches. 80% of problems are lifestyle related. We need behavior changes. We need to be leading Tai chi in the parks. This is not about nurses going into communities to make sure people take their medications. This involves family and communities. We need a mutually inclusive approach. There is a chaos out that and at the same time there the chance of an opening."6. David Jones, MD: "Policies aren't important if we haven't the clinical models"For the past eight years, David Jones, MD has been the president of the Institute for Functional Medicine, taking work begun by a trained chemist, Jeff Bland, PhD, and focusing it around clinical services. When we sat down for a visit in the speaker ready room, he made it clear that policy is not his first priority.
Jones: "My mind goes to how we make the healthcare experience more authentic for healthcare practitioners and clients. None of these healthcare policies are important if we don't have the right clinical models; if we don't train healthcare providers to have an authentic relationship with their patients. My sense is the technocrat-thinking has pushed out the magic inherent in the therapeutic relationship. If you look at efforts that sustain clients in their journey, it's usually based on the safety and trust engendered by the relationship with their healthcare provider. My answer may not be the answer you want. We need to care about policies that support a context of change. We need to have more education that puts together the plausible evidence to encourage learning and the elements necessary to creating authentic relationships. If we don't have laboratories where that is happening, changing healthcare policy is like rearranging desk chairs on the Titanic without changing the direction of the ship."
7. Tori Hudson, ND: "Work together in a shared entity or with a shared lobbyist"A 28-year clinician and educator in integrative medicine, naturopathic style, Tori Hudson, ND presently directs A Women's Time, a multi-practitioner center and maintains an additional private practice on the Oregon coast. She has teaching relationships with three naturopathic medical colleges and is a co-founder of Naturopathic Education and Research Consortium through which she and colleagues are actively promoting additional clinical residencies for naturopathic physicians. I caught her between two meetings on the exhibit floor.Hudson: "If I think about the health of the population and changing demographics and the aging, I'd say that being included in Medicare reimbursement is a key focus. The thing I'd say about my own ND community is getting qualified in rural health and Indian health programs. We have people who want to live in those communities. I don't really think about policy choices for all of the integrative practice community. But the first thing that comes to mind is we need to work together in some share entity or lobbyist. What is it? It would not be just for integrative MDs or nurses but any type of integrative practitioners to be integrated into it."8: Ka-Kit Hui, MD: “The integrative health community needs to be thinking about Berwick’s Tripe Aim”One of the very first integrative centers to be housed in an academic health center is the UCLA Center for East West Medicine, founded in 1993 and directed since by Ka-Kit Hui, MD. Hui, an international ambassador for East-West healthcare solutions, is presently exploring transforming his center into an East-West version of a medical home.Hui: "We have these centers but we are not well integrated into the system. To me it is the effort to make the value case to effect the compensation of the providers. It's the cost case, and it's the value case. We need the cost case and we need the clinical model. People are saying give me data but you have to have data from the right clinical models. Right now the integration that is there is not values based. We need in integrative health community to be thinking about the Triple Aim, the Berwick Triple Aim of care, health and cost. We need this focus to get more of these integrative practitioner centers to be developed, we need these data to get more low cost high touch care in the system."
Comment: A nice mix. One sees repeated themes. Warner and Luck on looking beyond typical clinical boundaries into communities, basics. Kligler and Hui on the importance of cost data. Gahles and Kligler on the non-discrimination opportunity relative to payment under the Affordable Care Act. Hui and Jones on the need for evidence of quality integrative models. Hudson and Warner on coming together as a community to speak with one voice and then to act together.
An integrative mind sees how these may each be viewed as part of a whole policy plan. This tees up Bland's suggestion. Can we find one state to model smart reimbursement just as some states are modeling new marijuana laws? Vermont? Oregon? A citizens initiative for payment reform anyone?