Recent content from the Academic Collaborative for Integrative Health (ACIH) invites readers to the convergence of two significant movements in U.S. medicine. One is conventional medicine’s efforts, advanced under the Affordable Care Act, to foster a team-based, community-oriented, outcomes-focused, patient-centered medical homes (PCMHs). The other is the movement for integrative health and medicine. The page combines the two, “Integrative Patient-Centered Medical Homes.”
Despite strong perception of alignment of values among integrative medicine leaders, PCMH’s are rarely developed by integrative clinicians. In fact, opposing business models of concierge and direct pay increasingly attract integrative practitioners. In these, the practitioner becomes less entangled with the medical industry’s halting moves from volume to value, for which the PCMH is the standard bearer in primary care.
The ACIH project, led Jennifer Olejownik, PhD, quickly takes a surprising turn. While the site speaks of a value convergence that has “increased the opportunities for integrative health providers” the text quickly narrows the project’s lens. “The roles of the profession that can claim to have first modeled integrative medicine, naturopathic physicians, in modeling these new forms of care are often invisible,” it says.
The set of three integrative PCMH’s that Olejownik profiles as part of ACIH’s Project for Integrative Health and the Triple Aim (PIHTA), are each led by naturopathic physicians. The project was funded in part by the naturopathic profession’s testing agency, the North American Board of Naturopathic Medical Examiners with other funding from an office management software firm, Visual Outcomes. Two of the naturopathic PCMH’s are based in Oregon, and one in Vermont. The report characterizes these states as “two of the most progressive healthcare states in the nation, where naturopathic doctors are eligible to lead PCMHs.” Each of the three reports from Olejownik are based on interviews with five to six practitioners or managers, and run roughly 20 pages. The reports are titled:
- A Profile of The Center for Natural Medicine
- A Profile of The National University of Natural Medicine (NUNM)
- A Profile of The Mountain View Natural Medicine
Olejownik describes the mission of her qualitative exploration. “Because there exists a paucity of documentation and literature on [integrative] PCMHs, this report was drafted as an exploratory attempt to understand some of the issues, barriers, successes, and challenges related to the operation of these environments. This document represents findings from conversations held with naturopathic doctors and other integrative providers working in an [integrative] PCMH.”
The portrait that emerges may prove paradoxical for integrative practitioners seeking entrepreneurial and business skills needed to build solo practices, which may seem a larger part of one’s duties than the clinical care that is their interest. At the Portland, Oregon-based Center for Natural Medicine, most patients are directly referred from the state, particularly via the state’s Medicaid program. For the employed practitioners, this can be a relief. Scrambling for patients is less an issue.
Yet, to work successfully in the “data rich environment”, the clinician must gain new skills. One said that he “supplemented the practical learning [of the clinic’s training program] by engaging in self-study routines when he was outside the clinic.”
Once the re-learning was complete, however, the PCMH clinical environment was deemed freeing. “Being in a larger group, a lot of things are handled by others which frees my hands to focus on clinical aspects and I much prefer that.”
A second practitioner spoke similarly. “I have support from the staff … and it works out well for me. I can focus on patients and not on the business side of things, which can get complicated, because we see all types of patients – Medicaid, cash., insurance.”
Integrative practitioners who welcome the focus on clinical care may be attracted to another aspect of this PCMH in Oregon. Internal referral is reportedly very easy, fostering the team orientation that is aligned with integrative values. Olejownik quotes one. “The best thing for me is being able to have people see different doctors for issues or conditions that are the most pertinent or specialized – the best person can help with aspects of a case.”
The challenges of the intersection of historic models of naturopathic practice and the PCMH come to the fore. “In an allopathic medicine, you have 7-15 minutes with patients,” says one naturopathic doctor at the National University of Natural Medicine clinic. “Our visits go between 30-60 minutes and that was a good model 30 years ago and I don’t think it works very well anymore … We have to streamline what we are giving them.”
The reports provide little data to illuminate the interviews. An exception is a set of slides from an internal survey of patients appended to the report on Vermont’s Mountain View Natural Medicine. High patient satisfaction was found on a quartet of questions regarding ease of access to care, whether they felt “respected and how well they were listened to,” how well care was coordinated, and “how complete or holistically [they] were treated”.
Comment: Olejownik’s general perspective suggests a positive alignment between the naturopathic profession and the PCMH model.
However, when one leaves the experiences in the clinics and enters the teaching environment— a perspective not explored in the earlier series—the report takes the reader on a remarkable side journey. Questions about the fit of naturopathic medicine with the PCMH dive into a deeper dialogue about the future of that profession. I will explore the NUNM model, and that dialogue, in an upcoming piece.