[Senate Hearing 111-387]
[From the U.S. Government Publishing Office]
S. Hrg. 111-387
PRINCIPLES OF INTEGRATIVE HEALTH:
A PATH TO HEALTHCARE REFORM
=======================================================================
HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
ON
EXAMINING PRINCIPLES OF INTEGRATIVE HEALTH, FOCUSING ON
A PATH TO HEALTHCARE REFORM
__________
FEBRUARY 23, 2009
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut MICHAEL B. ENZI, Wyoming
TOM HARKIN, Iowa JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico RICHARD BURR, North Carolina
PATTY MURRAY, Washington JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island JOHN McCAIN, Arizona
BERNARD SANDERS (I), Vermont ORRIN G. HATCH, Utah
SHERROD BROWN, Ohio LISA MURKOWSKI, Alaska
ROBERT P. CASEY, JR., Pennsylvania TOM COBURN, M.D., Oklahoma
KAY R. HAGAN, North Carolina PAT ROBERTS, Kansas
JEFF MERKLEY, Oregon
J. Michael Myers, Staff Director and Chief Counsel
Frank Macchiarola, Republican Staff Director and Chief Counsel
(ii)
C O N T E N T S
__________
STATEMENTS
MONDAY, FEBRUARY 23, 2009
Page
Mikulski, Hon. Barbara A., a U.S. Senator from the State of
Maryland....................................................... 1
Kerr, Charlotte Rose, RSM, R.N., B.S.N., M.P.H., M.Ac. (UK),
Practitioner and Professor Emeritus, Tai Sophia Institute,
Laurel, MD..................................................... 4
Jonas, Wayne B., M.D., President, Samueli Institute, Alexandria,
VA............................................................. 7
Prepared statement........................................... 9
Gordon, James S., M.D., Founder and Director, Center for Mind-
Body Medicine, Washington, DC.................................. 20
Prepared statement........................................... 22
Kreitzer, Mary Jo, Ph.D., R.N., Founder and Director, University
of Minnesota Center for Spirituality and Healing, Minneapolis,
MN............................................................. 27
Prepared statement........................................... 30
Duggan, Robert M., M.A., M.Ac., President, Tai Sophia Institute,
Laurel, MD..................................................... 60
Prepared statement........................................... 61
Baase, Cathy, M.D., Global Director of Health Services, Dow
Chemical Company, Midland, MI.................................. 63
Prepared statement........................................... 65
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Prepared statements of:
Herbert Benson, M.D. and Gregory L. Fricchione, M.D...... 101
Brian Berman, M.D., and Susan Hartnoll Berman............ 105
Gary Deng, M.D., Ph.D.; Wendy Werber, N.D., Ph.D.,
M.P.H.; Amit Sood, M.D., M.Sc.; and Kathi Kemper, M.D.,
M.P.H.................................................. 107
Ron Z. Goetzel, Ph.D..................................... 135
Kathi J. Kemper, M.D., M.P.H., FAACP..................... 139
Simon Mills, M.A., FNIMH, MCPP........................... 149
(iii)
PRINCIPLES OF INTEGRATIVE HEALTH:
A PATH TO HEALTHCARE REFORM
----------
MONDAY, FEBRUARY 23, 2009
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The committee met, pursuant to notice, at 2:00 p.m. in room
SD-430, Dirksen Senate Office Building, Hon. Barbara A.
Mikulski presiding.
Present: Senator Mikulski.
Opening Statement of Senator Mikulski
Senator Mikulski. The Committee on Health, Education,
Labor, and Pensions will now come to order. Today, the Working
Group on Quality, a path to saving lives and saving money, will
come to order.
Today's hearing will examine the principles of integrative
healthcare and discuss how to best include these principles
into the design of what we hope will be a new healthcare format
for the United States of America.
Discussing healthcare and healthcare changes is not simply
about expanding access to acute care or even expanding access
to physicians' care, though they will be a pillar to what
Congress ultimately does.
Even with access to more doctors, if our food is sprayed
with pesticides and comes from undisclosed origins--we could
have every child in the District of Columbia see a doctor, but
as long as there is lead in the water, the children will have
severe consequences. We also need to be able to look at how, at
the end of the day, our healthcare is not oriented to an
insurance system, but oriented to a patient system.
Our goal in the healthcare reform debate is to focus on
improving quality of care. That is the assignment that Senator
Kennedy gave me. Our purpose is to see that people are
healthier, diseases are prevented, chronic care conditions are
appropriately managed, and we work with the private sector in a
way where this, whatever we do, is affordable and sustainable.
Integrative healthcare is a key component to improving
health quality. This hearing is designed to be part of the
week-long discussion that is going on in Washington, DC.
Starting on Wednesday, the Institute of Medicine will have its
own 3-day summit on integrative medicine.
Today, I am holding this hearing of distinguished
practitioners and thinkers in the field to essentially kick off
the national debate. We are actually going to be ahead of the
Institute of Medicine. Then, on Thursday, Senator Harkin and I
will also be chairing two additional panels to continue the
discussion.
Senator Harkin and I, and other members of the committee,
feel so strongly about this that we are devoting a week-long
conversation to this topic. It is rare and unusual for any
Senate committee, particularly in the area of domestic policy,
to take a topic and really delve into it.
We feel so strongly about this because what we want to be
able to do is not reform an existing insurance system, but to
transform the delivery of healthcare. In order to do that, we
want to be sure that we hear from the people who really have
had the most experience. We know that many of you will be
talking about lessons learned, principles to be recommended,
and ideas that need to be incorporated in the healthcare
debate. We are so excited to see you.
Because of the robust participation in the IOM study, we
could have had a whole day just here. We are going to follow an
unusual format today. What we are going to do is have really
experienced people in the integrative healthcare field at the
witness table. At the same time, we have also distinguished
resource people that we are going to engage in the debate.
What I want to do now is introduce the people who are going
to participate in the panel, and at the same time identify the
wonderful resource people here.
First of all, I want to thank each and every one of you for
coming. But most of all, I want to thank you for what you do
every day.
Each and every one of you, who are both at the table and
also as part of our resource people, make a difference. You
make the difference in people's lives by the hands-on care that
you deliver or the services that you administer or the research
that you guide. Many of you have won national and even
international awards. At the end of the day, people's lives
have been better off because of what you do.
I can say this, as the U.S. Senator who will be working
with Senator Kennedy and, hopefully, on a bipartisan basis to
transform healthcare, that each and every one of you are making
a difference. When we work together, we can make change.
That is what America is asking us to do. Not only to change
an insurance system--to add one more preventive test, to fund
one more access to a boutique program--but to really transform
healthcare. But to be able to do it in a way that the business
they work for can afford to provide it, and as families and
individuals, they can afford to buy it. What they want to buy
into is not the same old, same old, same old.
That is what we are here today to talk about. This is an
official hearing and will be part of the official congressional
record in which we invite all policy people to look at and to
examine, just as they will be looking at the results of the
Institute of Medicine's summit on integrative healthcare.
Today, when you sit at this table, you are helping make
history. As our Presidents say, now that we are making history,
let us change history. We want to now welcome to the table
people who are quite experienced in the field.
The person who will kick off the hearing and give an
overview is Sister Charlotte Rose Kerr, a Sister of Mercy,
professor emeritus at the Tai Sophia Institute. She has also
been an assistant professor at the University of Maryland
School of Nursing and served on President Clinton's White House
Commission on Complementary Medicine, and she has been a member
of the NIH Advisory Council on Complementary Medicine.
We have Dr. Wayne Jonas, who is president and CEO of the
Samueli Institute. Dr. Jonas is an assistant professor of
family medicine at USUHS, our distinguished military medical
school. He was a Walter Reed doctor and also was the first
director of the Office of Complementary Medicine at NIH.
We have Mary Jo Kreitzer, the founder and director with the
Center for Spirituality and Healing at the University of
Minnesota. This center coordinates integrative health and
medicine programs at the medical, nursing, and pharmacy school.
We also have Dr. Jim Gordon, who is a clinical professor at
Georgetown School of Medicine. Dr. Gordon chaired the NIH
Commission on Complementary Medicine. He also chaired President
Clinton's White House Commission on Complementary Medicine. He
has been active not only in the practice of integrative
medicine, but also in taking these bold new ideas to the Middle
East; where we need to do a lot of integration and a lot of
healing.
We also have Bob Duggan from the Tai Sophia Institute. He
is the founder of the Tai Sophia Institute, an academic center
that trains people in acupuncture, herbal treatments, and
botanical treatments; he has also been a leading educator in
providing integrative healthcare and has a lot to share with us
on health and wellness services. We listened to much of the
thinking when we were in Howard County the other day, the whole
idea of a health coach, which makes having the medical home
worth living in.
Then we turn to Cathy Baase, who works for Dow Chemical.
She is the global director--wow--the global director of health
services. She is in charge, really, of ensuring that the Dow
Chemical workers get the best healthcare available, but she
also has a responsibility to shareholders that whatever is
delivered must be affordable and sustainable.
We feel that we have so much to learn from our private
sector, particularly those who have either been self-funded or
self-initiated, because it sounds like you have created your
own health reform over there at Dow. We are looking forward to
hearing about your health reform because we can learn from and
incorporate your lessons.
In our resource group, we have Cathy Kemper, a
distinguished practitioner from the Department of Pediatrics at
Wake Forest University; Mr. Ron Goetzel from Emory University
who heads up the Thomson Reuters healthcare area; Drs. Brian
Berman and Sue Berman. Dr. Berman heads up the complementary
medicine practice at Kernan Hospital and has won many national
and international prizes. He has been a lead collaborator with
the NIH in that area.
We regret that Dr. Herbert Benson, professor emeritus at
Harvard, could not be with us, but he has submitted a paper,
which we will include in the record, and also Mr. Simon Mills,
who is a special advisor to the UK parliament on the concept of
integrative medicine that is being done in the UK.
We believe that trans-Atlantic alliances should not only be
for the defense of the homeland against predatory attacks.
There are a lot of predatory attacks against our people. Mr.
Mills is advising the parliament, and we want to benefit from
his advice. His paper will be included in the record.
[The information previously referred to can be found in
Additional Material.]
That is by way of background. We have quite a lot to listen
to and to learn. To kick it off, I will now turn to Sister
Charlotte Rose Kerr for her introductory remarks.
STATEMENT OF SISTER CHARLOTTE ROSE KERR, RSM, R.N., B.S.N.,
M.P.H., M.Ac. (UK), PRACTITIONER AND PROFESSOR EMERITUS, TAI
SOPHIA INSTITUTE, LAUREL, MD
Sister Kerr. Thank you, Senator. I think you can hear me
now?
Senator Mikulski. Yes.
Sister Kerr. Madam Chairwoman, before I begin, I would like
to share with you the ground from which I speak, and I speak to
you as a Sister of Mercy. I speak to you as an educator, as a
nurse, as an acupuncturist, and, perhaps most importantly, I
speak to you as a southern woman.
My task today is to set the stage for this hearing,
entitled ``Principles of Integrative Health: A Path to
Healthcare Reform.'' Many of us here today share a sense that
this time of crisis in national healthcare brings an
opportunity for profound change in the structure and the
content of healthcare.
Today, we will talk about just what is an integrative
approach to healthcare. Who are we? Who are the people involved
in integrative healthcare? What do we feel is necessary to
create our healthcare system and restore the vitality to
America?
What we mean by integrative healthcare is expressed so well
by my colleague Jim Gordon, who will speak shortly, and I agree
with his description. It is an approach to healthcare that
includes those forms of helping and healing--whether previously
described as conventional, complementary, or alternative--which
have proven to be most effective and makes them available to
all Americans in comprehensive and individualized programs.
We need to include in our healthcare system surely
medication, but also meditation. We need acupuncture, and we
need surgery. We need group support in sustaining programs of
self-care as well as individual diagnosis and consultation in
designing these programs.
Of course, at the core of all health is the quality of our
community health, or our public health. There isn't one of us
in this room today who could create a blade of grass this
spring, and there isn't one of us in this room who would have
cured a cough this winter. All of us in healthcare are only
assisting nature to do what it can do.
Not one of us could provide a nutritious diet to our
families if the land has lost its nutrients and its spirit or
if the water is tainted or toxic. No healthcare system, no
matter how integrated, can support the body politic without the
health of the planet. This is primary and foundational to all
health.
Again, Jim's clarity can't be beat here. He says that we
need to recover the perspective in which the highest quality of
healthcare is seen as promoting personal, emotional, social,
and spiritual fulfillment. We must develop educational systems
and programs that manifest this perspective. For all of us
serving in healthcare, we need to re-dedicate ourselves to the
vocation to which we have been called--to heal and to serve.
Who are we, in integrative healthcare? Well, we are people
serving in healthcare, people who saw a deficiency in the
present healthcare model and began the journey to claim an
ecological model of health and healing. This is an approach
that recognizes the interrelationship of the health of the
individual, the environment, the community, the wider
community, on to the cosmos.
Many of these people hold credentials in traditional
Western medicine as well as other licensed healthcare
modalities, for example, naturopaths and chiropractors and
neuromuscular therapists, acupuncturists, and so many more.
I will give you a cameo of my own healthcare credentials,
which reflects the kind of experience many people bring to this
growing movement. I have experienced working in a leprosy
hospital as a registered nurse, managing patient care in the
diabetes clinic at the University of Maryland, clinical
experience in geriatrics and pediatrics and community health.
I have a master's in public health and served as assistant
professor at the University of Maryland School of Nursing. I
have a master's degree in traditional acupuncture and for 32
years have served as practitioner and faculty at Tai Sophia
Institute in Maryland.
What brings us here today began as a quiet revolution by
patients and practitioners, and now it is a social movement. At
the beginning, many people viewed elements of this new paradigm
as exotic--acupuncture, for example, and herbal medicine and
bioenergy. Today, many of these aspects are mainstreamed. They
are even common sense.
Nixon's trip to China in 1972 exposed millions of citizens
to other modalities of healthcare, and we went from the Nixon
trip to the Eisenberg study, which showed that, in 1997, 42
percent of Americans were using alternative therapies.
Then we moved on to the White House Commission on
Complementary and Alternative Medicine in 2002, and what is
called complementary and alternative and integrative medicine
has gone from exotic to mainstream. Some researchers estimate
that 70 percent of Americans currently use a form of
complementary therapy.
This committee, under the direction of Senator Kennedy, has
done pioneering work. Then there is Senator Harkin's faithful
work at the NIH and the Office of Complementary and Alternative
Medicine. Senator Mikulski, your work to get women included in
research protocol at NIH and an establishment of Offices of
Women's Health at NIH and FDA has led to really amazing
results.
As this committee deliberates on healthcare reform, I would
recommend that it truly focus on, first, reformation and
transformation of our system. Essentially, bringing new
thinking that is better for people and has better outcomes,
outcomes that can be sustained through practices of self-care.
Our current system is not producing health, and it costs
too much. All Americans need a healthcare safety net for their
ease of the mind and the heart. The resulting stress due to
this unmet need is as huge a contributing health risk factor
for many, many people.
Second, health promotion and prevention, we need to have a
system that regards health promotion and prevention as
important as treatment.
Third, we need a renewal of the education of healthcare
professionals, and this is as challenging a task as our
challenge of changing the healthcare system. My colleagues are
going to elaborate on this need.
These points and so many others, such as care for the
healers and body/mind/spirit care, will be stated, validated,
and further explored today as we discuss integrative
healthcare. Finally, I offer one more point, and that is the
establishment of an Office of Health and Wellness.
At this time, it seems clear and necessary that in order to
forward this transformation in healthcare, an Office of
Wellness and Health should be established at the White House
under the new health czar. This office would guide policy and
legislation focused on creating a wellness culture and
industry.
Hope is the action we take right now for our future. Even
though we stand in unknowing about that future, we trust
ourselves to find a new way to heal and to serve. As we go
through this evolving cultural transformation, we know that new
structures do need to be born, and we cannot be stopped by
circumstances. We will concentrate on the rightness of this
vision of integrated healthcare and trust we are working for
the common good of the people of the United States of America.
President Obama, in his inaugural address, said, ``Starting
today, we have to pick ourselves up, dust ourselves off, and
begin again the work of remaking America. Everywhere we look,
there is work to be done.''
We are ready and willing and expect to be surprised by the
transformed healthcare system that will manifest.
Thank you for your attention.
Senator Mikulski. Thank you very much, Sister.
Each and every one of you submitted extensive testimony,
and I am going to ask unanimous consent that your full remarks
be included in the testimony.
Now, I am going to turn to Dr. Jonas and then to Dr.
Gordon, who also, in addition to their practice, their
thinking, etc, have already also worked with large government
organizations--whether it has been our State Department,
whether it has been the Department of Defense--to get their
perspective on what needs to be done and how that worked.
Then I would like to go to the educational aspects and turn
to Dr. Kreitzer and Mr. Duggan and then really wrap up with the
private sector's insights and recommendations.
Dr. Jonas.
STATEMENT OF WAYNE B. JONAS, M.D., PRESIDENT,
SAMUELI INSTITUTE, ALEXANDRIA, VA
Dr. Jonas. Thank you, Senator Mikulski and members of the
committee, for this invitation to testify, to talk about how
integrative healthcare and the perspective on wellness can
address some of the ills that our healthcare system has today,
and to present a roadmap for integrative healthcare's inclusion
in national healthcare reform.
Senator, you have already mentioned my credentials. I won't
go over that. I will mention one thing. I still practice and
see patients up at the National Naval Medical Center--our
soldiers, our warriors, and families--on a weekly basis. And I
can tell you, if our national healthcare system is on a slow
burn, the Department of Defense's is on a rapid burn.
They are looking for things out of the box, innovative new
programs. You will see a number of things that we can learn
from in those areas.
I will mention briefly about the Samueli Institute. We are
a nonprofit medical research organization that investigates
healing, the application of health and wellness, and prevention
in disease. We are one of the few organizations that has a
track record in research on complementary and alternative
medicine and healing relationships, optimal healing
environments, and military medicine.
I am convinced that applying some of the principles of
wellness and integrative healthcare can ensure lasting effect,
lasting reform, reduce costs, stimulate investment, enhance
productivity, improve the health of our Nation, and,
importantly and often not mentioned, reduce suffering.
Sister Kerr mentioned that we do not have a healthcare
system in this country, and that is true. We have a very
impressive medical treatment system, especially for acute
illnesses, but we do not have a healthcare system.
A few facts. We spend almost twice as much as any other
country in healthcare, and yet we are 37th on the health
indicators within this country. At current cost rates,
healthcare will make up 25 percent of our GNP by 2025. If that
were to continue, by 2082, it would make up almost half of our
GNP, obviously an untenable situation.
The first of the baby boomers will begin to turn 65
starting next year, creating an avalanche of aging care needs
that will bury our medical care and our Medicare system. We
cannot expect to improve the health of our citizens simply
through more and better access. You have made this point. We
need a new vision for creating health in the country.
The ironic thing is we actually know how to do this.
Science has shown us the roadmap. We have good evidence for it.
Over 70 percent of chronic illnesses are due primarily to
lifestyle and environmental conditions, including substance
use, smoking, diet, alcohol, the environment, inadequate sleep
and exercise, stress management and resilience production,
social integrations and support, and selective disease
screening and immunizations. These are all modifiable
behavioral conditions.
A Milken report recently showed that we would be able to
save in the neighborhood of hundreds of billions of dollars in
treatment costs if we took a proactive preventive approach in
these areas, and trillions of dollars in productivity would be
added to our economy.
We also know that health and disease are not a threshold.
They are a continuum. We can now see--with technologies,
imaging, genomics, proteomics, we can see diseases evolving. We
can see the risk factors. We know they are there. We can see
them coming down the track, so to speak. We know when the train
is coming down the track.
It is no longer rational or scientifically sound to wait
until disease reaches an advanced diagnostic threshold and then
throw at it late and expensive interventions. It makes no sense
to do this. Self-care and integrative healthcare practices that
address these behaviors and processes can address these issues
to reduce pain, improve quality of life, and enhance well-
being.
This body, the Congress, and the President recently signed
a stimulation bill of several billion dollars. One billion of
that was for comparative effectiveness research. Some of this
money could test the ability of lifestyle change and
integrative approaches to prevent disease, enhance
productivity, and reduce patient suffering.
Let me give you one example of that. There have been
several direct comparative studies of the use of acupuncture in
common pain syndromes, comparing it to the best conventional
care that we currently have--things like headache, chronic back
pain, arthritis. Most of these studies have shown that
acupuncture produces about twice the effect of our best
conventional when looked at head-to- head.
Similar studies are needed with mind-body approaches to
induce the relaxation response. My colleague Herb Benson, who
couldn't be here, is a champion of that and has demonstrated
that. Massage, natural drugs, behavioral medicine, and other
healthcare approaches.
With the input of many, the institute has developed
something we are calling the Wellness Initiative for the
Nation, or WIN, that provides specific recommendations to----
Senator Mikulski. Excuse me?
Dr. Jonas. WIN.
Senator Mikulski. Because for a minute, it sounded like
``wimp.'' I don't think that is where you were headed.
[Laughter.]
That is not a word associated with you, Dr. Jonas.
Dr. Jonas. WIN, WIN, WIN.
[Laughter.]
Senator Mikulski. OK. W-I-N.
Dr. Jonas. W-I-N. A Wellness Initiative for the Nation. A
copy of this document will be provided to the written testimony
and be included in the record.
[Editor's Note: Due to the high cost of printing, previously
published materials are not reprinted in the hearing record. Please see
http://www.siib.org/news/news-home/WIN-Home.html.]
The policies and principles of this approach are grounded
in the continuity of healthcare and the prevention of illness,
and you will hear testimony to many of those approaches today.
WIN would provide leadership to develop a health system in
the United States; produce a workforce such as the HealthCorps,
which you will hear in Senator Harkin's and your testimony
coming on Thursday; produce information technology that
supports prevention and wellness; and the incentives for
producing a culture and an industry of wellness.
The program describes several phases as to how that
approach would be produced in a step-wise manner. Those are in
the record. I won't go over all of those. However, I do want to
point a couple out that are consistent with some of the other
things that have been said here.
First, we need leadership, and the leadership needs to come
from an executive or congressional effort to focus specifically
on developing a wellness industry. We have a medical industry.
We have a medical culture. We need a wellness culture.
We also then, second, need to coordinate and align current
health promotion and prevention policies. There are a number of
them, such as that put forward by the Partnership for
Prevention and Healthy People 2010.
We then need to establish models, demonstration models
throughout the lifecycle as to how those wellness approaches
can be done. I mentioned that the DOD is on a rapid burn. Our
healthcare system in the DOD is not working very well because
of the high stresses--the post traumatic stress syndrome, the
chronic disease that is being produced by the wars.
They are moving ahead and rapidly developing new and
innovative areas, including integrative practices, for our
service members and families. We should take those lessons
learned and bring them into the national area.
In conclusion, if these recommendations are applied in a
coordinated fashion, this will be not just a triple multiplier,
but a quadruple multiplier, enhancing education, health,
productivity, and an economic stimulus for the Nation.
I appreciate the opportunity to appear before the committee
and look forward to any questions. Thank you.
[The prepared statement of Dr. Jonas follows:]
Prepared Statement of Wayne B. Jonas, M.D.
Thank you, Senator Mikulski, and members of the committee for the
invitation to testify about the potential of integrated health care to
address many of the ills of today's health care delivery system; and
present a roadmap to ensure integrated health care's inclusion in the
national health care reform debate. My name is Wayne Jonas. I am a
retired Army family physician; I see patients weekly at a Military
Medical Center; and am President and CEO of the Samueli Institute of
Alexandria, VA, and Corona Del Mar, CA. I have formerly served as
Director of the Office of Alternative Medicine at the National
Institutes of Health, the Director of the Medical Research Fellowship
at the Walter Reed Army Institute of Research, a Director of a WHO
Collaborating Center of Traditional Medicine and a member of the White
House Commission on Complementary and Alternative Medicine Policy.
The Samueli Institute, a 501(c)(3) non-profit scientific research
organization, investigates healing processes and their application in
promoting health and wellness, preventing illness and treating disease.
The Institute is one the few organizations in the Nation with a track
record in complementary and integrative medicine, healing relationships
and military medical research.
I am convinced of the importance of applying integrative health
care principles to the health reform process to ensure lasting reform,
to reduce costs and to improve the health of our Nation. The United
States does not have an effective health care system. We are first in
health care spending but 37th in health of the industrialized nations.
At current cost rates, health care will make up 25 percent of the GNP
by 2025 and 49 percent by 2082. The first of the ``baby boomers'' will
turn 65 in 2011 creating an avalanche of aging care needs that will
bury the current Medicare system. We cannot expect to improve the
health of our citizens through more or better access to the current
system. We need a new vision and approach to creating health.
Science has clearly demonstrated that 70 percent of chronic illness
is due primarily to lifestyle and environmental issues, including
proper substance use (smoking, alcohol, drugs, diet, and environmental
chemicals), adequate exercise and sleep, stress and resilience
management, social integration and support, and selective disease
screening and immunization. We know that health and illness are a
continuum. It is unreasonable to wait until disease reaches an advanced
diagnostic threshold, and then provide expensive late-stage
interventions. We must pursue prevention, health promotion, chronic
disease management and healing--a new vision of health and disease
based on self-care and lifestyle management. Self-care and integrative
health care practices can reduce pain, improve quality of life and
enhance well-being.
The recent stimulus package passed by Congress has set aside $1
billion for comparative effectiveness research. Some of this money
should test the ability of lifestyle change and integrative practices
to reduce patient suffering and prevent disease. For example, several
recent studies have directly compared the effect of acupuncture to the
best conventional therapies in the treatment of common and costly pain
problems, such as headache, neck and back pain, and arthritis. These
studies have shown that acupuncture is often twice as effective as what
we do now. Similar studies are needed with the relaxation response,
massage, behavioral medicine, and other self-care approaches.
With the input of many, the Institute has developed A Wellness
Initiative for the Nation document which provides specific
recommendations to proactively prevent disease and illness, promote
health and productivity, and create well-being and flourishing for the
people of America. A copy of the document is provided to accompany my
written testimony for inclusion as part of the hearing record. The
policies and principles of the approach are grounded in the continuity
of health and the prevention of illness throughout the human lifecycle
by applying comprehensive lifestyle and integrative health care
approaches that have demonstrated effectiveness.
The Wellness Initiative for the Nation approach is multi-faceted
with the following recommended reform steps to be pursued in a phased
manner.
Phase 1: Create a working group and coordinating office at
the Executive or Congressional level. This office would focus
specifically on creating policies and programs for lifestyle-based
chronic disease prevention and management, integrative health care
practices, and health promotion.
Phase 2: Establish a lead systems wellness advancement
team (SWAT) of national leaders to guide the office.
Phase 3: Define the ``new paradigm'' that is the focus of
the wellness initiative for the Nation, to include the key vision,
strategies, and tactics as well as the effective elements and metrics
of comprehensive lifestyle and integrative health care practices.
Phase 4: Collate, coordinate and align current health
promotion and prevention policy efforts.
Phase 5: Establish models for delivery of national
wellness initiatives and acknowledge the lessons-learned by the
Departments of Defense and Veterans Affairs.
Phase 6: Create and evaluate new wellness demonstration
projects across the human lifecycle and in various different settings,
for example with children, worksites, military veterans and aging.
Phase 7: Create parallel legislative tracks to support and
incentivize effective public and private wellness initiatives
throughout the Nation.
In conclusion, if these recommendations are applied in a
coordinated fashion, a ``triple multiplier'' of health, productivity
and economic stimulus would result for the Nation.
I appreciate the opportunity to appear before this committee and I
look forward to any questions. Thank you.
______
Attachment.--A Wellness Initiative for the Nation
A Wellness Initiative for the Nation (WIN)--Summary Document
PURPOSE
The purpose of the Wellness Initiative for the Nation (WIN) is to
proactively prevent disease and illness, promote health and
productivity, and create well-being and flourishing for the people of
America. WIN can also prevent the looming fiscal disaster in our health
care system. In fact, effectively addressing preventable chronic
illness and creating a productive, self-care society is our only long-
term hope for changing a system that costs too much and is delivering
less health and little care to fewer people.\1\ \3\
OVERVIEW AND RECOMMENDATIONS
The overarching recommendation is to create a Wellness
Initiative for the Nation focused on promotion of health through
lifestyle change and integrative health practices. WIN would be
overseen by the White House, with a Director and staff to guide
relevant aspects of health reform, as described in the recent report,
The Health Care Delivery System: A Blueprint for Reform (the
``Blueprint'').\4\
WIN will focus primarily on accomplishing goal three of
the Obama/Biden Health Reform Plan--``improve prevention and public
health''--and support development of an educational workforce and
informational toolkit for delivery of this goal in local populations.
WIN leadership will provide program analysis, develop policies, guide
curriculum and evidence standards, and establish incentives and
mechanisms that support these efforts in national health care reform.
WIN will align with overarching goals of the ``Blueprint''
and Healthy People 2010 (Increasing Quality and Years of Healthy Life
and Eliminating Health Disparities) \5\ and link to recommendations
such as the ``Wellness Trust,'' \6\ a ``Federal Health Reserve,'' \7\
the Institute of Medicine's reports on health care quality,\8\
transformation,\9\ integrative medicine,\10\ and the White House
Commission on Complementary and Alternative Medicine Policy.\11\
The initial step of WIN is to create a White House office,
with a Director and staff, specifically focused on developing policies
and programs for lifestyle-based chronic disease prevention and
management, integrative health care practices and health promotion.
The policies and programs of WIN would be grounded in the
continuity of health and the prevention of illness throughout the human
lifecycle and would approach this continuity through comprehensive
lifestyle and integrative health care approaches that have demonstrated
effectiveness.
Other specific recommendations are as follows:
1. Systems Wellness Advancement Teams Network (``The Innovators'')
Establish a network of Systems Wellness Advancement Teams
(SWAT) with national and then local leaders in health promotion/disease
prevention and integrative practices to maintain the wellness vision
and guide the White House in the implementation of this new paradigm.
Empower the SWAT network to continuously evaluate and
translate effective prevention and health promotion practices into
local delivery tools and policy changes.
Create learning communities that evaluate and translate
innovations in lifestyle and integrative health practices into new
settings and populations across the network.
2. Health and Wellness Professional Coach Training (``The Advocates'')
Establish educational and practice standards in delivery
of effective, comprehensive lifestyle and integrative health care
approaches, and train individuals qualified to focus full-time on
prevention, creating health and healing, and enhancing productivity and
flourishing.
Facilitate any qualified and State-licensed health care
practitioner or educator to gain specialist certification in
prevention, health and wellness delivery, or attain sub-specialist
status for integrative health care delivery in specific settings and
populations--for example, schools, worksites, health care settings, and
long-term care facilities.
Create a Health Corps to provide an army of young and
older people that would learn and model wellness behavior and support
delivery of wellness education and training by the coaches.
3. Health and Wellness Information Technology Toolkit (``The Avatars'')
Create an advanced information tracking and feedback
system (an applied health promotion technology toolkit) for delivery of
personalized wellness education, customized to each person's level of
readiness, IT capabilities and stage of life.
Interface this applied wellness toolkit with electronic
health records for use by the public, the health and wellness coaches,
the Health Corps, and the medical and health care delivery systems.
Coalesce current health promotion/prevention knowledge
into a science-based Health Quotient Index (HQI) for personalized
delivery of information to individuals and communities through multiple
interface.
4. Economic and Social Incentives (``The Industry'')
Create economic incentives (through bundling, capitation,
premium reductions, tax reductions and other methods) for individuals,
communities, and public and private sector institutions to create and
deliver self-care training, wellness products and preventive health
care practices.
Establish intellectual property protection policies that
reward wellness innovations, using the latest technologies with
evidence-based and comparative cost-value determinations.
Establish incentives for both personal and community
activities that establish social and cultural change, which creates
public wellness values and a flourishing society.
These recommendations are designed to work in a coordinated fashion
on the specific leverage points of cultural and institutional change.
If applied in concert, these recommendations are a ``triple
multiplier'' of health, productivity and economic stimulus for the
country by: (1) creating new jobs in the educational, health and
technology sectors; (2) increasing health and productivity across the
population in both the short- and long-run; and, (3) stimulating
innovation and investment by the private sector into the creation of a
health and wellness industry and society.
The United States is first in spending for health care but 37th in
health status among industrialized nations. If applied in concert,
these recommendations are a ``triple multiplier'' of health,
productivity and economic stimulus for our Nation.
A PHASED PROGRAM
The WIN will use a phased approach to assure that prevention and
health promotion programs are rolled out in a coordinated, systematic,
stepwise and effective manner with full input from the public and
stakeholders involved in wellness delivery. Recommended phases include:
Phase 1: Create a working group and coordinating office within the
White House that is specifically focused on creating policies and
programs for lifestyle-based chronic disease prevention and management,
integrative health care practices and health promotion;
Phase 2: Establish a lead Systems Wellness Advancement Team (SWAT)
of national leaders in health promotion, disease prevention, and
integrative practices to guide the office;
Phase 3: Define the ``new paradigm''--the key vision, strategies,
and tactics and the effective elements and metrics of comprehensive
lifestyle and integrative health care practices that will be the focus
of WIN;
Phase 4: Collate, coordinate and align current health promotion and
prevention policy efforts such as, House Concurrent Resolution 406, The
Health Promotion First Act, the Healthy Workforce Act, The Health
Project, the 1st Dollar Clinical Preventive Services Coverage, the
Medicare Improvement Act, the Public Health Advisory Committee, and
consensus statements by the Partnership for Prevention, the Prevention
Institute, the American College of Occupational and Environmental
Medicine, and other programs and recommendations \12\;
Phase 5: Use and evaluate current Department of Defense, Veterans
Health Affairs, Medicare and workforce health, performance enhancement
and wellness initiatives to rapidly establish models for delivery of
national WIN projects;
Phase 6: Create and evaluate new demonstration projects in each of
the WIN lifecycle populations (e.g., children, worksites and aging; see
below for details) to improve the cost-value of national programs
created by the WIN; set up selection, modeling and evaluation
parameters using indices such as COMPARE and Health Impact Assessment
(HIA) processes \13\ \14\;
Phase 7: Create parallel legislative tracks to support and
incentivize effective public and private wellness initiatives
throughout the Nation.
BACKGROUND
In his book The Power of Progress, John Podesta summarizes the
situation succinctly. ``It is not enough to merely expand access to the
current system. Americans must also secure better value for their
health care dollars through improved health care quality, outcomes, and
efficiency. First, we must create a national focus on disease
prevention and health promotion. The United States is plagued by
preventable diseases that have a devastating impact on personal health
and contribute to the Nation's soaring health costs. Yet our current
system focuses on treating these diseases after they occur, rather than
promoting good health and reducing the incidence of disease in the
first place.'' \2\ (pg. 182)
Too many Americans go without high-value preventive services and
health promotion practices.\5\ As a result, they get sick and utilize
expensive medical interventions.\1\ Examples of underutilized
preventive and health promotion practices include cancer screening to
prevent advanced colon disease, immunizations to protect against flu or
pneumonia, fitness and resilience training to enhance productivity and
well-being, self-care and integrative health practices to treat chronic
pain and enhance healing, and healthy lifestyle education to prevent
diabetes, hypertension, stroke, cardiovascular disease and cancer.
The Nation (and increasingly the world) faces epidemics of obesity,
mental illness and chronic disease, as well as new threats of pandemic
flu and bioterrorism.\15\ \16\ Yet despite all of this, less than four
cents of every health care dollar is spent on prevention and public
health.\17\ We are first in spending for health care and 37th in health
of the industrialized nations.\18\ At current cost rates, health care
will make up 25 percent of the GNP by 2025 and 49 percent by 2082!\19\
The first of the ``baby boomers'' will turn 65 in 2011, creating an
avalanche of aging care needs that will bury the current Medicare
system. Our health care system is a broken disease treatment system,
and the time for change is well overdue.
True prevention and health promotion requires something different
than just access to current services. It requires a new vision of
health and disease based on the primary components of human
flourishing. Science has now clearly demonstrated a radically new view
of chronic health and disease than the one developed over 100 years ago
and currently in use. No longer is it reasonable to wait until disease
reaches an advanced diagnostic threshold before our system provides
expensive interventions.
The Cost of Avoidable Chronic Illness
A recent Milken Institute report showed that the combined
cost of the top seven modifiable chronic diseases (cancer, diabetes,
hypertension, stroke, heart disease, pulmonary conditions, and mental
disorders) exceeds $270 billion per year in direct care costs and, with
the addition of lost productivity, reaches over $1 trillion
annually.\20\
These costs are largely avoidable by changes in behavior.
A modest focus on prevention, early intervention and behavioral change
could save annually in treatment and productivity loss costs an
estimated $217 billion and $1.6 trillion, respectively. This could add
over $6.9 trillion to the GDP between now and 2023--27 percent of the
GDP's economic impact.
Modest gains in just smoking and obesity control, for
example, would reduce illness in the top seven conditions by 24-30
million, save up to $100 billion in treatment costs, and add from $340-
$500 billion to the GDP in the next 15 years.
Application of the top 20 proven clinical preventive
services (CPS) would save an additional $4 billion in treatment costs
and increase quality of life years by over 2 million.\21\ WIN will
focus on effective delivery for the 10 CPS recommendations that address
core primary prevention and lifestyle change factors.\21\
Suffering associated with chronic disease and pain
produces an even greater burden, the cost of which is not quantifiable.
Self-care practices can reduce pain, improve quality of life and
enhance well-being.\22\ \23\ \24\ Complementary health care practices
are especially useful in this regard.\25\ \26\
Causes of Avoidable Chronic Disease
Seventy percent of avoidable costs could be mitigated by
behavior changes that involve healthy lifestyle development, wellness
enhancement, and early detection and intervention for the conditions
listed above. Two-thirds of chronic illness is caused by lifestyle and
behavioral factors that are influenced by our mental, social or
physical environments.\27\
Five behavioral factors contribute the most to mitigating
costs and to increasing sustainable wellness. These are: (1) reducing
toxic substance exposure (smoking, alcohol, drugs and pollution); (2)
sufficient exercise; (3) healthy diet; (4) psychosocial integration and
stress management; and (5) early detection and intervention.\20\ \28\
To achieve gains in wellness and productivity requires a
change in the nature of the culture and services provided to our
communities. Increased access to our current disease treatment system
is not sufficient and will increase costs. We need a concerted
investment in creating a flourishing human capital focused on
prevention, productivity, healing and well-being.\29\
components of human health behavior and productivity optimization
We know now that health and disease are a continuum and we know the
fundamental elements that move us along that continuum. Both before and
after the threshold, between health and disease, the basic elements of
health promotion can slow or prevent chronic disease progression and
enhance function, productivity and well-being. No matter what the
illness or stage of life we now know that the same components of human
health behavior and productivity optimization apply. These components
are:
1. Stress Management and Resilience. The first component is the
induction of mind-body States known to counter the stress response and
improve readiness and motivational factors for lifestyle change. Recent
research has demonstrated that mind/body practices can be taught and
can counter the physical and psychological effects of stress, prevent
PTSD, increase fitness and weight management, and enhance cognitive and
physical function.
2. Physical Exercise and Sleep. The second component is physical
exercise. Optimum physical exercise can reduce stress hormone swings
and improve brain function, improve fitness and enhance weight control.
Fitness, along with proper rest and sleep, and rapid management of
injury from physical training, will maintain functioning and
productivity.
3. Optimum Nutrition and Substance Use. Third, ideal weight and
optimal physiological function occurs best in the context of proper
nutrition and reduced exposure to chemicals (such as smoking, alcohol
and drugs) that impair function. Food and substance management requires
systematic motivational systems, environmental control, food and
substance selection training, and family and community involvement.
4. Social Integration. Finally, the social environment is key.
Social integration is not only health enhancing in its own right, but
is essential for sustainability of behavior change. Health promotion is
best achieved in a group and community context, in which common issues
in the culture around behavior and lifestyle change are valued and
shared with peers, friends and family. Both health and happiness are
socially contagious. Social integration allows individuals, their
families and communities the opportunity to spread healthy behavior and
find day-to-day solutions for maintaining well-being and resilience.
A culture and industry that values and optimizes these components
will produce a flourishing, productive society. In addition, the
impending economic disaster of continuing to solely apply the current
sickness treatment system to our rapidly aging population can be
altered at its core. The policy recommendations of WIN are designed to
focus directly on optimizing these components for individuals and
communities.
creating sources of prevention, productivity, healing and wellness
Public policy should support, stimulate and enhance each
individual's inherent wellness and healing capacities since this
provides the most powerful force we have for maintaining health and
productivity when well, and for enhancing recovery and well-being when
ill.\30\
Approaches to the prevention of chronic disease, detection
of early risk factors, and enhancement of well-being are well known but
not done well or systemically by our health care system.\1\
Central to a new model of prevention and health care are
the development of Optimal Healing Environments (OHE) \31\ and
integrative health care practices \26\ that can support and stimulate
inherent healing capacities on mental, social, spiritual and physical
levels. As described below, many of these practices provide lower cost
alternatives to current conventional practices.\32\ \33\
Of the ``Blueprint'' recommendations, WIN will focus
specifically on supporting areas in ``Patient Activation'' (pp. 81-95)
and ``Public Health'' (pp. 96-111) but also contribute to other areas,
including nurse and geriatric training (p. 9, 23), wellness information
technology (p. 27, 47), and developing bundling, capitation and tax
relief approaches for delivery of evidence-based health promotion and
integrative health care practices (p. 69-71).
MODELS OF SUCCESSFUL PREVENTION AND HEALTH PROMOTION
The Military
The military has been at the forefront of health promotion and
performance enhancement innovations for decades and has recently
developed a renewed effort in ``human performance optimization.'' \34\
The non-profit Samueli Institute is working closely with a coalition of
military partners to develop the next generation ``Systems Wellness
System'' as a model for combining systems biology with lifestyle change
to develop personalized prevention and health promotion tools.\35\ This
program could become a model for national application.
Health Care Delivery Systems
The health care delivery industry has a major role in advancing
prevention and wellness and the ``Blueprint'' is primarily focused on
this area. A recent study of eight ``exemplar'' OHE programs in health
systems demonstrated the ways in which WIN could translate current
innovations in health promotion and healing into our health care
systems.\36\ The use of health information technology could further
extend skills in health promotion and self-care and disease management
beyond the walls of the hospital and into communities and the home.\37\
Self-Care and Integrated Care
The widespread application of selected, evidence-based integrated
health care practices could markedly improve quality of life and reduce
costs.\33\ Behavioral and mind-body practices have been repeatedly
demonstrated to enhance quality of life, improve self-care and reduce
costs.\38\ Acupuncture has now been definitively shown to improve
chronic pain conditions (head, neck, knee and back) at almost twice the
rate of guideline-based conventional treatment.\39\ \40\ Massage may
be even more cost effective in back pain.\41\ Massage has also been
shown in multiple studies to accelerate recovery of premature babies,
with projected cost savings of $4.7 billion per year if widely
used.\42\ Training retired persons to deliver this infant massage
results in reduced depression and enhanced quality of life in those
giving the massage--a double benefit.\43\ Herbs and dietary supplements
are widely used by the population but with little to no guidance on
what is safe and effective.\44\ Under current policies, these practices
and products are not sufficiently profitable to provide economic
incentives for research and investment. Thus, they remain under-
investigated and unutilized at the expense of higher cost and more
heroic treatment approaches. A properly focused wellness policy would
change this situation.
Worksites
It is now well established that multi-component worksite wellness
programs enhance productivity, well-being and return on investment
(ROI) in industry.\45\ For example, Procter and Gamble and the Dow
Chemical Company have improved productivity and reduced health care
costs, with a positive ROI for their programs at multiple sites.\46\
\47\ Companies are now extending these efforts to reducing costs of
medical treatment and for chronic disease prevention and
management.\48\ Health promotion efforts for America's workers is a
double multiplier for the economy by improving productivity and
creating jobs.\49\ The C. Everett Koop Awards of The Health Project
have selected some of the most successful and innovative health
promotion programs that could be applied nationally by the WIN.\50\
Community-Based Programs
Community-based, comprehensive lifestyle modification programs have
demonstrated effectiveness for mitigating cardiovascular risk
factors,\51\ stroke prevention,\52\ smoking cessation,\53\ treating
obesity \54\ and osteoporosis,\55\ and diabetes prevention,\56\ as well
as other chronic conditions.\57\ In Japan, comprehensive lifestyle
modification programs including physical exercise and diet/nutrition
education have been implemented and extensively evaluated in work sites
and in elderly populations, and results have shown dramatic
improvements for obesity and lifestyle-
related disease.\58\ The Centers for Disease Control and Prevention
(CDC) has targeted community-based programs as an effective vehicle for
delivering health promotion and disease prevention campaigns.
Children
The Wellness Initiative for the Nation will select the best of
these programs and develop policies to establish them throughout the
United States. The long-term impact of such policies would be a golden
age of health, productivity and well-being; a flourishing and great
society.
Wellness must start with children by teaching them lifelong healthy
habits. Healthy habits need to be a core competency delivered by our
educational system. A number of exemplar programs in schools have
produced major impacts on wellness behavior, including effects on
obesity. For example, a school program for underserved elementary
school children has demonstrated improved health behaviors that spread
to families and the surrounding community.\59\ Other examples are the
Planet Health Program, and the VERB Program.\60\ \61\ \62\ \63\ \64\
The Wellspring Academy's schools, camps and community programs have
produced marked success in improved weight management, enhanced self-
esteem and improved mental health during adolescence, a difficult time
of life to affect change.\60\ \65\
Aging
Our population is rapidly aging, resulting in ballooning of chronic
disease and illness. The majority of health care costs are expended in
the last years of life. The older population is highly motivated for
self-care and makes extensive use of complementary and alternative
practices, some helpful and some harmful.\66\ \67\ Extending functional
years through prevention (such as vaccination), early detection (such
as screening), lifestyle and self-management training can also reduce
costs of chronic disease treatment. For example, simple procedures
(such as providing a health coach or call nurse) significantly reduce
health care costs and mortality in cardiovascular disease.\68\
Extension of health care into the home with TeleHealth (the delivery of
health-related services and information via telecommunications
technologies) could further maintain function and reduce costs in the
senior population up to 70 percent with current technologies.\69\ \70\
\71\ A set of recently funded Centers for Medicare & Medicaid Services
(CMS) demonstration projects of health promotion in older people are
examples of programs that serve as national models under the WIN.\72\
The Underserved
The widening gap in health disparities is one of the major moral
failures of our society.\73\ Social isolation and socio-economic class
are major determinants of chronic disease and premature death.\27\ The
poor often seek out and use self-care and complementary medical
practices, but get little guidance on which practices are effective or
harmful.\74\ Self-care and integrative health care approaches, when
properly delivered, can significantly improve health in these
populations. For example, a recent Medicaid demonstration project
providing integrative health care found an 86 percent reduction in
pain, 25 percent reduction in health care utilization and 20 percent
reduction in prescription drug use in an underserved community.\75\
\76\ The Samueli Institute, along with the Institute for Alternative
Futures and the Health Resources and Services Administration recently
brought together integrated health care programs for the underserved as
possible models for WIN.\74\
These examples are only a few of the practices that could improve
health, productivity and well-being, and reduce costs from disease and
disability in our Nation. For other examples involving disease
screening, vaccination, nutritional practices and educational programs,
see the governmental summaries on those areas.\5\ \77\ \78\ \79\ \80\
\81\ \82\ \83\ \84\ \85\ \86\
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Senator Mikulski. Thank you, Dr. Jonas.
Dr. Gordon.
STATEMENT OF JAMES S. GORDON, M.D., FOUNDER AND
DIRECTOR, CENTER FOR MIND-BODY MEDICINE,
WASHINGTON, DC
Dr. Gordon. Thank you, Senator Mikulski.
It is wonderful to be here today, Senator Mikulski, and to
hear your words and to feel the spirit and the energy with
which you deliver them. I really appreciate your bringing us
here together to talk about health and to talk about wellness.
What I want to do is, first of all, echo what my colleagues
have said and then to talk about a few particulars that I think
are very important. The first thing is that we are at a moment
of potentially profound change. In my mind, I think of it as a
kind of Copernican moment.
Up until now, we are in a kind of medieval State where we
have all these extremely complicated theories and behaviors
that are simply not either producing better health or producing
economies. Much of the effort that has been made in recent
years is to shore up systems to develop new ways of doing the
same old thing.
You said it beautifully when you said this is not about
reforming the insurance system. It is about transforming our
whole healthcare system.
What I think is most important, that I want to address to
you and to other members of the committee and to all of us who
are here, is that our whole consciousness has to change, and
that so many of those things which, as we say in Washington,
have been taken off the table need to be put back on the table.
We need to look at what is actually going on and what is
actually, as Sister Charlotte and as Wayne have just said, what
actually has a chance for making a profound difference in the
way we care for our population and also economically.
I would start by saying that one of those items that needs
to be put back on the table is a single-payer healthcare
system. Physicians for a National Health Plan estimates that if
we were to not only not reform the insurance companies, but
essentially to take over the work of insuring our whole
population, as every other industrialized country does, that we
would save $350 billion to $450 billion a year. Very important
savings.
Not only that, we would create a foundation from which we
could begin to refocus, to take the focus off disease and to
put the focus on health or wellness. We know already that the
way the system is going, it is bankrupting us. Nationally, it
is bankrupting many of our major corporations.
That is the first point. Let us take that one from the
floor and put it back on the table. The second is to refocus
away from disease, as both of my colleagues have said, and to
focus on wellness.
The disease model works brilliantly in some areas, but it
doesn't address the major problems that we have either
individually or as a society. It really doesn't address very
well 80 to 90 percent of the issues, concerns, problems, and
conditions that American people, both children and adults,
have. What will address those is a program, a comprehensive
program of teaching people the fundamentals of self-awareness,
self-care, and mutual help.
If we could bring in effective techniques of stress
management, if we could bring in nutrition supplemented not
only by vitamin supplements, but supplemented by an attention
to the environment, if we could also use physical exercise, we
could prevent or successfully treat in a major way most of the
conditions that most of us suffer from.
We need to shift our attention in a clinical--not only in
terms of setting up prevention programs. Currently, only 5
percent of our budget at NIH, maximum, goes to prevention. It
should be 50 percent of our budget going to prevention.
We need to shift in the direction of prevention, and we
need to bring those approaches to self-awareness, self-care,
and mutual help, mobilizing communities and families to help
one another into the center of our healthcare system. If we do
that, we can not only prevent, but we can reverse some of the
major conditions that afflict us.
Dean Ornish's work--and perhaps you will be hearing about
that on Thursday--with heart disease shows very clearly that
using self-care, using exercise, meditation, relaxation, group
support, dietary change, we are able to reverse coronary artery
disease.
The work that we have done with entire populations that
have been traumatized by war in Kosovo, Bosnia, Gaza, Israel,
and now back here with military coming back from Iraq and
Afghanistan, shows that we can teach people, individuals who
have been in combat and their family members, how to understand
and help themselves and how to heal the conditions from which
they suffer, which might otherwise disable them for their whole
lives.
The second area that is so crucial is looking at the
education of our children. Our kids are actually in worse
health than we were as kids, and the situation is getting worse
and worse every year. We need to bring--there has been too much
of a focus--I am all for reading--and reading and writing and
arithmetic. They are crucial. They are crucial to my work. They
are crucial to all our work.
But those kids who are so anxious, who are so belabored and
beleaguered biologically, who are suffering, beginning to
suffer already from attention deficit disorder and
hyperactivity, who are depressed and anxious and getting ready
or already having diabetes and hypertension, those kids aren't
going to be able to learn unless we teach them how to take care
of themselves. We have to create wellness programs in every
school.
Now there is a mandate, a Federal mandate for school
wellness programs, but nowhere that I know of are they truly
effective in any State in this country. That seems to be a
major area that we need to become involved in. If we do that,
we can do so much to prevent all the chronic diseases that we
are now forced to treat well down the road.
Finally, I want to second what Sister Charlotte said in the
beginning, which was also a recommendation of the White House
commission that I chaired. And that is that we need to have an
office at the highest level in the White House that is going to
ensure that the kinds of transformation that you and Senator
Harkin and others who have been concerned about this for so
long are going to catalyze and get off the ground. We need to
ensure that is going to continue over time.
It is not something that is restricted to HHS. As you have
heard, it is the Defense Department. It is the EPA. It is the
Department of Agriculture. It is the Department of Education.
There needs to be coordination at the highest level to ensure
that the wellness of our population is our national priority.
Thank you very much.
[The prepared statement of Dr. Gordon follows:]
Prepared Statement of James S. Gordon, M.D.
MAKING WELLNESS AND SELF-CARE THE HEART OF ALL HEALTH CARE
Chairman Kennedy, Ranking Member Enzi, Senator Mikulski, members of
the committee, I'm very pleased to be with you this afternoon. I'm a
psychiatrist, founder and director of The Center for Mind-Body
Medicine, and a clinical professor of psychiatry and family medicine at
Georgetown Medical School. I bring to you today a perspective shaped by
40 years of work as a clinician, researcher, and teacher, as Chair of
the Advisory Council of the NIH's Office of Alternative Medicine, and
Chair of the White House Commission on Complementary and Alternative
Medicine Policy. The recommendations I make are my own and they are
shaped by years of discussions with many colleagues, patients, and
friends.
We are poised on the verge of a necessary revolution in our health
care. It has become clear that an overwhelming attention to disease, an
endlessly multiplying system of reimbursable diagnostic tests and side-
effect burdened drugs and procedures are actually combining to produce
more, not less, suffering in the United States; the health of
Americans, according to the World Health Organization, ranks 37th on
our planet. We live shorter lives and have higher infant mortality than
a host of other industrialized countries, and we spend twice as much as
they do on our care: the cost to our national treasury is 16.5 percent
of our Gross Domestic Product, and growing every year. It's time, more
and more of us realize, to shift our focus from treating disease to
promoting health and wellness, from symptomatic treatment to systematic
prevention. It is time also to take control of our health care from
those who profit from our ill health, to ensure that it responds to the
needs of all our people.
In response to a request from the Obama administration, 6 weeks
ago, hundreds of groups met around the country to discuss the health
care challenges that we face, to come up with new perspectives and
fresh ideas for health care. I invited 30 colleagues and friends, and
their friends, to my house to respond to this request. Their accents
and perspectives were as varied as the 30-person group--men and women
from their early twenties to early eighties, blacks and whites, Asians
and Hispanics, health care professionals, business people and policy
wonks, the wealthy and the barely getting by. Still, remarkably, as
each of us spoke of our greatest health care concerns, common themes,
common understandings, common solutions emerged--and with them a re-
evaluation of our health care system as revolutionary in its way as the
theories of Copernicus and Darwin.
In my written testimony, I provide 10 recommendations for
transforming health care that emerged from our discussion and from my
own 40 years of experience. Here I will offer three that seem most
salient and a fourth that will help ensure their continued growth and
development.
1. We need a coherent, rational system of National Health Care, a
single-payer system that, without demeaning and destructive
bureaucratic obstacles, meets the needs of all Americans. This
recommendation was supported by successful, stressed-out health
professionals and beleaguered parents, by self-styled liberals and
conservatives, and by policy analysts who months ago believed it was
``off the table'' of political discussion. In spite of any complexities
in its creation, it was regarded as the ``only sane'' remedy. Indeed,
one of our participants, a former head of mental health services for
the Veterans Administration, pointed out that a majority of U.S.
physicians and nurses already favor such a plan.
The crucial task, we feel, is to ask the Administration and
Congress to examine the available models--Medicare, government
employees' insurance, and military health in the United States, and the
national systems of other developed countries--and create one that is
most beneficial and suitable to our population: a system that
facilitates more free choice than the current one, and eliminates the
demeaning bureaucratic inquisitions that characterize current insurance
practice, while guaranteeing universal coverage and cutting costs.
Physicians for a National Health Plan and other advocates estimate that
we could reduce our entire health care bill by 20-25 percent, or $400-
$500 billion per year, by enacting a single-payer plan.
Single-payer can no longer be regarded as taboo, or off the table.
It is, to use an expression dear to physicians, a ``treatment of
choice'' for our national health care ills--not a panacea, but a
platform that makes other necessary changes possible, a structure that
offers our best hope for fairness, effectiveness, and economic
survival.
Though all participants regarded insurance companies as obstacles,
the chief proponents of profits over peoples' welfare, all felt it was
imperative that their employees be retained as workers in the single-
payer system or retrained for other careers, especially in health care.
2. Whatever model of universal care is chosen, it must be grounded
in a profoundly different point of view and practice from the current
one, a model in which prevention is as important as treatment and in
which self-care and mutual help are understood as fundamental to both
prevention and treatment.
This means that education about psychosocial and economic factors
in health and illness and practical instruction in the use of
nutrition, exercise, stress management, and mind-body approaches (like
meditation, guided imagery, biofeedback, and yoga) must come to be seen
and practiced as the true primary care. These effective and inexpensive
practices--``breathing, moving, learning how to shop,'' as one mother
of three put it--must be central to both prevention and treatment, used
wherever possible prior to more side-effect burdened approaches like
surgery and drugs, as well as along with them. This is not meant to
disparage drugs and surgery in any way. It is simply to put them in
their proper place in health care: vital remedies, with significant
hazards, to be used only when necessary.
All of our group believed that this approach was absolutely
essential to cost savings as well as our national health; that it
should be mandated as primary care. And all of us are firmly convinced
that this emphasis on self-awareness and self-care needs to be central
to the training of all health professionals, and that research on its
effectiveness in treating and preventing chronic illness cannot be an
afterthought for our government. It needs to be the central focus of
its attention and funding at NIH and elsewhere.
This approach to wellness and prevention does not, we believe,
require economic incentives and penalties as many have insisted--
carrots and sticks. It can be grounded in an entire system which helps
people who have felt discouraged and disrespected and alienated to
become actively engaged in their own care. I and other clinicians in
the room reported that when we treated our patients with respect,
taught them techniques they could use to help themselves, and provided
the kind of practical, emotional, and social support they needed to
sustain the changes they decided to make, health care miracles were
possible. Many of us, including The Center for Mind-Body Medicine staff
(and many of our professional trainees), have found this approach to be
highly successful with populations that are often regarded as
recalcitrant and incapable of self-care, including the low-income,
chronically ill elderly; delinquent adolescents; HIV-positive ex-
prisoners; and war-traumatized children and adults. Respected and
treated as equals who are capable of understanding and helping
themselves, offered the opportunity to use simple, practical tools of
self-care to live healthier and fuller lives, the vast majority
respond--and so will the vast majority of all Americans.
3. The transformation of the health of our population must begin
with our children. In this process, the Department of Education must be
understood as a central agency in health promotion and disease
prevention. Current school health programs are largely negative--
``don't smoke, don't drink, don't have sex, etc. etc.''--and largely
ineffective. The school wellness curricula that all States have been
ordered to develop are a good first step. Congress needs to ensure that
they are taken far more seriously, closely examined, and carefully and
completely implemented. True and comprehensive wellness--including
exercise, nutrition, stress management and self-expression--must become
a central part of all school curricula and of the lives, and the
teaching and learning experience, of all school personnel and of the
parents of school children, and of the health professionals who work
with both parents and children. Those who are teaching self-care must
themselves learn and practice it, and the homes that children live in
must support their children's efforts to help and care for themselves.
4. A White House Office of Health and Wellness. As we surveyed
these and other changes we were recommending, it became clear to our
group--and has become clear to other groups and leaders around the
country--that a small but powerful agency at the highest level of our
government is required to ensure continued responsiveness to the
ongoing and changing health needs of Americans.
I respectfully recommend therefore that a White House Office of
Health and Wellness be established. This office (which would in some
ways be similar to the White House Offices of Science and Technology
and Drug Policy) would ensure, along with Congress, that government
bureaucracies (including any required for National Health Care as well
as the NIH, the Departments of Education, Agriculture, and Defense and
the Veterans Administration) are accountable to a vision in which
service to all Americans is paramount, and to the implementation of
programs, like the school wellness program, which make this vision a
reality. The White House Office--and its representative National
Advisory Board--would help ensure ongoing active engagement of our
population in their own care and in shaping the kind of care that will
most effectively, humanely, and economically meet all our evolving
needs.
______
Attachment.--Report on the HealthCare Community Discussion
RECOMMENDATIONS SUBMITTED TO PRESIDENT OBAMA
The accents and the perspectives were as varied as the 30-person
group--men and women from their early twenties to early eighties,
blacks and whites, Asians and Hispanics, healthcare professionals,
business people and policy wonks, the wealthy and the barely getting
by. Still, remarkably, as each of us spoke of our greatest health care
concerns, common themes, common understandings, common solutions
emerged.
Healthcare is ``too expensive,'' said the first speaker, an FDA
scientist calling up other countries' statistics. ``My neighbor,'' a
currently unemployed old friend, ventured, ``gets $2,600 a month in
disability and pays $1,500 for her insurance. How can you live like
that?'' ``My daughter and her husband,'' an active-duty Army colonel
told us, ``are actually getting divorced so Medicaid will cover my
grandchild's surgical bills.'' ``We are,'' concluded a former high
Clinton administration official, a serious man suddenly sad, ``the only
advanced country where people without insurance go bankrupt.''
Everyone agreed that catastrophic care after a car accident or in a
surgical or medical emergency was often excellent, but that the model
of swift and decisive intervention had been long misapplied. ``We have
a `sick care,' not a health care system,'' a black family physician
told us, to a general nodding of heads. ``I can't bill for obesity or
smoking cessation.'' The current system, everyone agreed, often
reimburses for expensive treatments of questionable value, instead of
supporting preventive and self-care approaches. Small businesses,
including doctors' offices, we heard, cut services and raise fees to
meet the escalating costs of their own employees' healthcare--``It's
more than 15 percent a year,'' a second family physician, who'd brought
his budget with him, told us. Anxiety about health and coverage, our
participants said again and again, contributes to the illnesses that
demand coverage, and keep poorly covered people from seeking the help
they need. The costs mount out of control while our national health
grows worse--we spend far more money, our group members said with pain,
incredulity, and outrage, live far less long and have far higher rates
of infant mortality than just about any other industrial society.
Still, in spite of the pain, disappointment, and the frustration
that providers, patients, and policymakers have all repeatedly
experienced, they still feel, there was, all around the circle and
throughout the evening, a sense of promise and a feeling of hope in the
room. Everyone deeply appreciated that the opinions of the American
people were finally being asked for and that their voices would be
heard. This time of crisis in our national health care, we agreed, can
be an opportunity for profound change in the structure and the content
of our healthcare, a time to eliminate the waste and ``collateral
damage'' of our current system and to cut its killing costs, an
opportunity to create a health care system devoted to people, not
profits.
At the end of the evening, I summarized the most robust
recommendations that were emerging from the rich soil of our
conversation, the ones we would make to the Obama-Daschle team. Here
they are:
1. We need a coherent, rational system of National Health Care, a
single-payer system that, without demeaning and destructive
bureaucratic obstacles, meets the needs of all Americans. This
recommendation was supported by successful, stressed-out health
professionals and beleaguered parents, by self-styled liberals and
conservatives, and by policy analysts who months ago believed it was
``off the table'' of political discussion. In spite of any complexities
in its creation, it was regarded as the ``only sane'' remedy. Indeed,
one of our participants, a former head of mental health services for
the Veterans Administration, pointed out that a majority of U.S.
physicians and nurses already favor such a plan.
The crucial task, we felt, was to examine the available models--
Medicare, government employees' insurance, and military health in the
United States, and the national systems of other developed countries--
and create one that was most beneficial and suitable to our population:
a system that facilitated more free choice than the current one, and
eliminated demeaning bureaucratic inquisitions while insuring universal
coverage and cutting costs. Though all participants regarded insurance
companies as obstacles, the chief proponents of profits over peoples'
welfare, all felt it was imperative that their employees be retained as
workers in the single-payer system or retrained for other careers,
especially in healthcare.
2. Whatever model of universal care is chosen, it must be grounded
in a profoundly different point of view and practice from the current
one, one in which prevention is as important as treatment and in which
self-care and mutual help are understood as fundamental to both
prevention and treatment.
This means that education about psychosocial and economic factors
in health and illness and practical instruction in the use of
nutrition, exercise, stress management, and mind-body approaches must
come to be seen and practiced as the true primary care. These effective
and inexpensive practices--``breathing, moving, learning how to shop,''
as one mother of three put it--must be used wherever possible prior to
more side-effect burdened approaches like surgery and drugs, as well as
along with them. All of our group believed that this approach was
absolutely essential to cost savings as well as our national health;
that it should be mandated as primary care.
We realized as we listened to several military participants that we
have much to learn from the Armed Forces' emphasis on comprehensive
fitness programs which include mental, emotional, spiritual, social,
familial, and financial, as well as the physical, aspects of health.
This approach to wellness and prevention does not, we believe,
require economic incentives and penalties as many have insisted--
carrots and sticks. It can be grounded in an entire system which helps
people who have felt discouraged and disrespected and alienated to
become actively engaged in their own care. I and other clinicians in
the room reported that when we treated our patients with respect,
taught them techniques they could use to help themselves, and provided
the kind of practical, emotional, and social support they needed to
sustain the changes they decided to make, health care miracles were
possible. Many of us, including The Center for Mind-Body Medicine staff
(and many of our professional trainees), have found this approach to be
highly successful with populations that are often regarded as
recalcitrant and incapable of self-care, including the low-income,
chronically ill elderly; delinquent adolescents; HIV-positive ex-
prisoners; and war-traumatized children and adults. Respected and
treated as equals who are capable of understanding and helping
themselves, offered the opportunity to use tools to live healthier and
fuller lives, the vast majority respond--and so will the vast majority
of all Americans.
3. Integrative approaches to healthcare must be adopted as the
standard of care and rigorously studied. This means including in
National Health Care whichever forms of helping and healing--whether
previously described as conventional, complementary, or alternative--
have proven to be most effective and making them available to all
Americans in comprehensive and individualized programs: meditation and
medication, acupuncture and surgery, group support in sustaining
programs of self-care as well as individual diagnosis and consultation
in designing them.
4. Transforming the selection and education of health
professionals. The health professionals who will sustain and embrace
this new commitment to comprehensive care, self-care, wellness, and
prevention, must be imbued with idealism and humanitarianism, with a
primary devotion to science in the service of people, to patients, not
profits. To train and support them, we must create a system which
provides a free professional education with an emphasis on wellness,
self-care, and prevention as well as biomedicine, and, in return for
it, require compulsory public service for all physicians, nurses, and
other health professionals.
This system would foster the selection and education of the most
committed, gifted, and dedicated healthcare providers regardless of
financial background. It will give all health professionals both a
scientific understanding of the therapeutic power of self-care and
prevention as well as a profound personal experience of these
approaches. It will emphasize character, commitment, and genuine
concern for others equally with academic achievement.
5. The transformation of the health of our population must begin
with our children. In this process, the Department of Education must be
understood as a central agency in health promotion and disease
prevention. Current school health programs are largely negative--
``don't smoke, don't drink, don't have sex, etc. etc.''--and largely
ineffective. The school wellness curricula that all States have been
ordered to develop are a good first step. They need to be taken far
more seriously, closely examined, and carefully implemented. True and
comprehensive wellness--including exercise, nutrition, stress
management and self-expression--must become a central part of all
school curricula and of the lives, and the teaching and learning
experience, of all school personnel and of the parents of school
children. Those who are teaching self-care must themselves learn and
practice it, and the homes that children live in must support their
children's efforts to help and care for themselves.
6. We must create a sane alternative to the current overpriced,
counterproductive, indeed, destructive system of malpractice insurance.
This new option would separate financial compensation for patients from
re-education and punishment of health professionals and hospitals. A
national fund would fairly compensate those who have been injured by
medical and hospital error (the vast majority of whom, according to a
number of studies in New York and elsewhere, do not sue and are not
compensated) in a way similar to workman's compensation. Instead of
perpetuating the destructive narrowness of ``defensive medicine,'' this
new approach would provide genuine re-education for erring physicians
or--if their offenses warrant it--bar them from practice. This kind of
system, which is being successfully used in such countries as Norway
and New Zealand, must be investigated and refined to meet U.S. needs.
7. We must remove the baleful influence of the insurance and
pharmaceutical companies on healthcare quality and its cost, and make
industry serve, rather than exploit, Americans with health needs. This
includes eliminating health insurance companies from the health care
equation. They are formed for profit rather than service, and each year
add hundreds of billions of dollars ($350 billion according to
Physicians for a National Health Plan) of administrative costs,
executive pay, and shareholder profits to our health care bill. This
measure would require retraining and re-deploying the several hundred
thousand managers and workers in the insurance industry--equipping
those who are genuinely interested to provide health care and health
education. A national system of health care should have and use its
bargaining power to ensure true competitiveness among pharmaceutical
manufacturers and thereby significantly lower costs. Elimination of the
influence of direct-to-consumer advertising--deplored by health
professionals as well as patient advocates at our meeting--would
further lower costs as well as reduce unnecessary, propaganda-driven
drug-prescribing and drug-taking.
8. We must develop a research program which serves the needs and
priorities discussed above, one which helps set the agenda for our
Nation's health, rather than one that uncritically reflects a narrow
biomedical perspective. The NIH's 30-some billion dollar budget must be
put to the best possible use, with a far more significant percentage--
up from the current 2 percent to perhaps 20 percent--explicitly
dedicated to studying the effectiveness of prevention, self-care, and
wellness. An additional 20 percent of the budget needs to be shifted
away from the single intervention studies--one drug or one procedure--
on which NIH grants focus, to the study of comprehensive, integrative
and individualized programs of care for the chronic illnesses that
beset our population and consume our health care dollars, approaches
that appear to be likely to produce the best results--for example,
nutritional, mind-body, and exercise interventions for arthritis, heart
disease, and chronic pain; chemotherapy along with nutritional therapy,
acupuncture, herbs, and group support for cancer. Finally, 10 percent
of the budget that is allocated to single intervention studies should
be awarded to research on non-patentable approaches, including mind-
body therapies, herbal remedies, therapeutic dietary programs,
acupuncture, musculoskeletal manipulation, etc., etc.
9. We must recover the ancient philosophical perspective, in which
the highest quality healthcare is seen as promoting personal,
emotional, social, and spiritual fulfillment, and we must develop
programs that manifest this perspective. The military's health care may
be more effective than most civilian care because it has allegiance to
and is implemented in the service of a greater mission--the defense of
our country. A similar and perhaps even more life-affirming spirit--one
of enhancing our collective national life and of providing service to
our fellow citizens--can be called on and mobilized for civilian health
care.
10. A White House Office of Health and Wellness. As we surveyed the
changes we were recommending, it became clear to our group that a small
but powerful agency at the highest level of our government was required
to ensure continued responsiveness to the ongoing and changing health
needs of Americans. Therefore, we recommend that a White House Office
of Health and Wellness be established. This office (which would in some
ways be similar to the White House Offices of Science and Technology
and Drug Policy) would ensure that government bureaucracies (including
any required for National Health Care as well as the NIH, the
Departments of Education, and Defense and the Veterans Administration)
are accountable to a vision in which service to all Americans is
paramount. The White House Office would help ensure ongoing active
engagement of our population in their own care and in shaping the kind
of care that will most effectively, humanely, and economically meet all
our needs.
The Center for Mind-Body Medicine is a 501(c)3 non-profit
organization.
Senator Mikulski. Thank you, Dr. Gordon.
That is pretty profound. Every one of you could be a
subject of an hour or longer hearing.
Dr. Kreitzer.
STATEMENT OF MARY JO KREITZER, PH.D., R.N., FAAN, FOUNDER AND
DIRECTOR, UNIVERSITY OF MINNESOTA CENTER FOR SPIRITUALITY AND
HEALING, MINNEAPOLIS, MN
Dr. Kreitzer. Madam Chair and members of the committee, it
is an honor to be asked to testify before this distinguished
body on an issue of such vital importance as healthcare reform.
As a nurse, I have worked as a nurse practitioner,
healthcare administrator, NIH-funded researcher, and I am
currently a professor of nursing at the University of
Minnesota, where I also direct an interdisciplinary,
integrative health center called the Center for Spirituality
and Healing.
Our healthcare system is on a trajectory that in many ways
mirrors what has happened in the financial system. There has
been greed, excess, and a failure to do what is right due to
vested interests. Putting more money into the same system will
only produce more of what we currently have, which I think we
would all agree is untenable.
I want to highlight several strategies related to the
integrative health that I think have the potential for being
transformative to the healthcare system.
You have heard from my colleagues about the importance of a
fundamental shift from a healthcare system that focuses on
disease to one that focuses on health. In my first public
health nursing course over 35 years ago, I learned the core
principle that it is cheaper to prevent disease than to cure
it. We need to get into the hands of consumers information,
tools, and resources that will enable them to better manage
their health and their healthcare.
We have a health coaching program at the University of
Minnesota--we have had it for 4 years--where we are preparing
health professionals to help people focus on comprehensive
lifestyle changes that includes the use of integrative health.
We have also created a Web site for consumers called Taking
Charge of Your Health that focuses on helping people learn how
to navigate the health system and to develop a personal plan
for health and well being.
As we shift from a system that focuses on disease to one
that focuses on health, nurses, the largest group of health
professionals in the country, are very well prepared to provide
leadership, to be a health corps for the Nation. We need to
rethink the workforce, particularly around primary care.
Numerous studies have confirmed that nurse practitioners
and physician assistants can effectively manage 80 percent of
primary care. Nurse practitioners in particular are educated to
focus on wellness, health promotion, and chronic disease
management, including the use of integrative therapies.
In 2008, Minnesota passed healthcare home legislation. We
call it a healthcare home, not a medical home. While the
primary care provider has traditionally been viewed as a
physician trained in typical specialties, such as family
medicine, pediatrics, and geriatrics, the Minnesota legislation
recognizes the importance of expanding the definition to
include nurse practitioners, physician assistants, and others
who provide primary care.
While not included by name in the Minnesota legislation,
there are licensed CAM providers who serve as the first
provider patient contacts and who need to be part of any
workforce solution.
In addition to developing new models of care that enable
primary care providers to practice to the top of their license,
we also need reimbursement mechanisms that are aligned with the
goals of health promotion and better management of chronic
disease. We have reimbursement for procedures, but not for
nutritional or lifestyle counseling.
Reimbursement levels from both public- and private-
sponsored programs are not based solely on the service
provided, rather the educational level of the provider.
Reimbursement for services, for example, by an advanced
practice registered nurse, such as a nurse practitioner or
certified nurse midwife, can range from 65 to 85 percent of the
physician fee.
This differential has the effect of discouraging clinics
from having advanced practice registered nurses provide
services for which they are very educated and capable and
encouraging the same services to be provided by physicians in
order to maximize reimbursement. This discrimination in
reimbursement occurs with CAM professionals, as well as
physician assistants and advanced practice registered nurses.
As daunting a task as it is to reform our healthcare
system, including the care models and reimbursement, I am here
to tell you that we face an equally daunting task in
transforming how we educate health professionals. There is
resistance to change, lots of incentive to maintain the status
quo, discrimination in how CAM institutions fare compared to
conventional institutions, and very few, if any, educational
programs that are truly transformative.
Faculty cultures in both CAM and conventional institutions
are deeply ingrained. We need innovation in education that is
based on a future view of healthcare that includes a focus on
health as well as disease, a different mix of health
professionals and a broader array of therapeutic approaches,
and consumers who are activated to take charge of their health.
If we invest in educational infrastructure, it is essential
that the focus be on innovation rather than the maintenance of
the status quo. I will close my remarks with an example of an
innovation that is bold and that could be transformative.
What if we were to leverage the strengths of schools of
nursing and CAM institutions across the country and have them
formally partner with community health centers in their
communities to create a truly comprehensive, holistic,
integrative healthcare model? This would require a new model of
reimbursement as well as care.
Then what if we were to go a step further and re-design the
curricula for students around this dynamic learning environment
in a way that there is a strong focus on health and that
students can actually interact and learn together? In addition
to providing access and care to patients, it would provide an
outstanding site for faculty practice and research as well as
student learning.
We know that community health centers are ideal health
homes. Multiple studies have shown the effects of being able to
reduce low-birth weight babies and hospitalization for people
who are chronically ill.
Using funds from the recently passed economic stimulus
package and awarded to HRSA, pilot projects could be funded
that would help us develop and evaluate a model of integrative
primary care. I also agree with my colleagues that to provide
the leadership necessary to launch the changes that we are
talking about today, I support the creation of a Federal office
that would be responsible for developing policies and programs
in support of a wellness integrative health agenda.
Thank you very much.
[The prepared statement of Dr. Kreitzer follows:]
Prepared Statement of Mary Jo Kreitzer, Ph.D., R.N., FAAN
Mr. Chairman, Madam Chairwoman and members of the committee, it is
an honor to be asked to testify before this distinguished body on an
issue of such vital importance as healthcare reform. As a nurse, I have
worked as a nurse practitioner, health care administrator, NIH-funded
researcher and am currently a professor of nursing at the University of
Minnesota where I also serve as the director of an interdisciplinary
integrative health program--the Center for Spirituality and Healing.
Our health care system is on a trajectory that mirrors what has
happened in the financial system. There has been greed, excess, and the
failure to do what is right due to vested interests. Putting more money
into the same system will only produce more of what we currently have,
which is untenable. Everyone in this room is well aware of the
statistics. We spend more money in our Nation on health care than any
other country in the world yet 46 million or more have no insurance and
thus limited access and we are ranked near the bottom of the industrial
world in health outcomes.
I want to highlight strategies related to integrated healthcare
that have the potential to be transformative to our healthcare system.
We need a fundamental shift in orientation from disease to
health and well-being. In my first public health course in nursing
school over 35 years ago, I learned the core principle that it is
cheaper to prevent disease than to cure it. We need to get into the
hands of consumers information, tools and resources that will enable
them to better manage their health and health care. We have a health
coaching program at the University of Minnesota where we are preparing
health and wellness professionals who are prepared to help people focus
on comprehensive lifestyle change which includes the use of integrative
health care approaches. We have also created a Web site for consumers
titled ``Taking Charge of Your Health'' that focuses on helping people
learn how to navigate the health system, serve as a health advocate,
and develop a personal plan for their health and well-being.
We need to re-think the workforce--particularly around
primary care. Numerous studies have confirmed that nurse practitioners
and physician assistants can effectively manage 80 percent of primary
care. Nurse practitioners in particular are educated to focus on
wellness, health promotion and chronic disease management including the
use of integrative therapies. In 2008, Minnesota passed health care
home legislation--we do not call it a medical home. While a primary
care provider has traditionally been viewed as a physician trained in
typical specialties such as family medicine, pediatrics, and
geriatrics, the health care home legislation recognizes the importance
of expanding the definition to include nurse practitioners,
pharmacists, physician assistants and others who provide primary care.
In this definition, primary care provider includes the first provider-
patient contact for a new health problem and ongoing coordination of
patient-focused care. There are licensed complementary and alternative
medicine (CAM) providers (naturopathic medicine, chiropractic and
acupuncture/Chinese medicine) who can meet this definition as well.
While not included by name in the MN legislation, licensed CAM
providers need to be part of the workforce solution.
We need new models of care that use primary care providers
to the highest and best use of their respective education and capacity,
that focus on health promotion as well as disease prevention and
chronic disease management, that make use of all therapeutic approaches
and providers including CAM, and that facilitate collaboration and team
delivery of care. We also need reimbursement mechanisms and incentives
that will help us get intended results. We remain locked in a fee for
service mentality. It is a very simple formula--the more services you
provide or tests and procedures you do, and the higher the price--the
more money the provider makes. As Clay Christensen noted in his book
the Innovator's Prescription--it encourages providers not to offer as
much care as needed, but to offer as many services as possible for
which there is coverage. In order to make ends meet for clinics,
providers are constantly trying to patch together procedures that will
help cover costs rather than focusing on what would help patients lead
healthier lives. The system is flawed in that it will reimburse for
procedures, but will not reimburse for a nutritional or lifestyle
counseling session. Reimbursement from both private and government-
sponsored programs reflect not the level of service performed, but
rather the educational level of the provider. Reimbursement for
services provided by advance practice registered nurses (APRNs) can
range from 65-85 percent of the physician fee. This differential has
the effect of discouraging clinics from having APRNs provide services
for which they are trained and capable and encouraging the same
services to be performed by physicians in order to maximize
reimbursement. Discrimination in reimbursement occurs with CAM
professionals as well as PA's and APRNs.
We need strategic investment in infrastructure,
particularly in the areas of research and education.
Research.--The stimulus package is providing a
desperately needed influx of funds for the research enterprise
which is badly underfunded. Instead of using these funds for
business as usual, it would be most helpful to have the
investment focus on research that is very applied--that will
create jobs--the research equivalent of ``shovel ready
projects.'' NIH has focused heavily on basic science research
over the past 8 years, we need translational and applied
research. Integrated health care is ripe for this and could
produce the innovation that is so badly needed within
healthcare reform.
Education.--As daunting as the task is to
fundamentally change our health care system including care
models and reimbursement, we face an equally daunting task in
transforming how we educate health professionals. There is
tremendous resistance to change, lots of incentive to maintain
the status quo, discrimination in how CAM institutions fare
compared to conventional institutions and very few, if any,
educational programs that are truly transformative. Faculty
cultures in both CAM and conventional institutions are deeply
engrained and are a major barrier to change. We need disruptive
innovation in education that is based on a future view of
health care that includes a focus on health (diet, nutrition
and exercise) as well as disease, a different mix of health
professionals, a broader array of therapeutic approaches, and
consumers who are activated to take charge of their health. If
we invest in educational infrastructure, it is essential that
the focus be on innovation, rather than maintenance of the
status quo.
To provide the leadership necessary to launch and manage this
initiative, it is recommended that a Federal office be established,
with a director and staff, who would be responsible for developing
polices and programs for lifestyle-based chronic disease prevention and
management, integrative health care practices and health promo-
tion.
Integrative health care holds the potential of shifting the current
U.S. health care system from one that is sporadic, reactive, disease-
oriented and physician-centric to one that fosters an emphasis on
health, wellness, early intervention for disease, patient empowerment,
and a focus on the full range of physical, mental, spiritual and social
support needed to improve health and minimize the burden of disease.
______
Prepared Statement of Mary Jo Kreitzer, Ph.D., R.N., FAAN, Director,
Center for Spirituality and Healing, University of Minnesota and
Tenured Professor, School of Nursing; Benjamin Kligler, M.D., M.P.H,
Associate Professor of Family and Social Medicine at Albert Einstein
College of Medicine and Research Director of the Continuum Center for
Health and Healing in New York; and William C. Meeker, D.C., M.P.H.,
President, Palmer College of Chiropractic, West Campus*
ABSTRACT
Over the past 3 decades, evidence has accumulated that demonstrates
that the U.S. health care system as currently structured is untenable
given the cost of health care, poor outcomes associated with this cost,
imminent shortages in many categories of health professionals and
underutilization of other health professionals. The system also faces
other challenges, such as the lack of access to care and a growing
demand by consumers for health care that offers choice, quality,
convenience, affordability and personalized care. Workforce analyses
estimating needs and anticipated shortages of health professionals are
projected on the current health care system which generally does not
include integrative health care and do not include complementary and
alternative medicine (CAM) practitioners. This paper examines the
opportunities and implications of going beyond the current paradigm of
workforce planning and health professions education and offers
recommendations that detail how the health of the public may be served
by incorporating an integrative health perspective into health
professions education and workforce planning, deployment and
utilization.
---------------------------------------------------------------------------
* The responsibility for the content of this article rests with the
author and does not necessarily represent the views of the Institute of
Medicine or its committees and convening bodies.
---------------------------------------------------------------------------
INTRODUCTION
Over the past 3 decades, evidence has accumulated that demonstrates
that the U.S. health care system as currently structured is untenable
given the cost of health care, poor outcomes associated with this cost,
imminent shortages in many categories of health professionals and
underutilization of other health professionals, lack of access to care
and a growing demand by consumers for health care that offers choice,
quality, convenience, affordability, and personalized care. It is well
established that the United States spends far more on health care than
any other nation, yet it ranks only 34th in the world in life
expectancy and has a higher infant mortality rate than many other
developed nations. A recent report on the State of the Nation's health
workforce by the Association of Academic Health Centers (2008)
highlighted what is described as dysfunction in public and private
health workforce policy and infrastructure that is contributing to
vulnerabilities for the workforce and putting the health of the
American public at risk. Issues identified include the following:
The current system of reimbursement is beset with
distortions, inequities and contradictions that have influenced and
shaped the health workforce over many years.
Market initiatives of the last 2 decades have engendered
perverse reimbursement incentives that do not address greater societal
needs.
Younger generations are deterred from entering the health
professions because of debt, compensation factors, hazardous work
environments, and reduced access to education.
The growth of the U.S. population, its increasing
diversity, and the aging of the baby boomers raise concerns about the
adequacy of the health workforce.
A lack of national leadership and alignment exists amongst
numerous educational, accrediting, and licensure bodies.
Health care needs of the public are largely left to the
States; State governments are inclined to focus on the specific needs
of their populations, without concern for greater national priorities.
A key finding of the 2008 report is that federally funded and
national workforce planning commissions have tended to have a limited
focus, often concentrating on one profession or a limited series of
issues, rather than a broad strategic vision. A recommendation ensuing
from this analysis is that a broader, more integrated national
strategic vision is needed if complex and urgent health workforce
issues are to be addressed effectively.
As comprehensive and bold as this recent analysis is, it falls
dramatically short in two respects. While it decries the historical
lack of comprehensive workforce planning, it focuses exclusively on
conventional health professionals including physicians, nurses,
optometrists, pharmacists, dentists, psychologists, public health
professionals, podiatrists veterinarians, and other allied health
professions (defined as dental hygienists, occupational, physical, and
respiratory therapists and physician assistants). It does not include
chiropractors, naturopathic physicians, traditional Chinese medicine
practitioners or any other type of CAM practitioner. Nor does it
describe what workforce needs might look like if we had a different
vision of health care, one that includes for example, integrative
health care. The report implicitly presumes that we need more of what
we have. This approach is consistent with that taken by the National
Center for Health Workforce Analysis (2008) in the Bureau of Health
Professions in the Health Resources and Services Administration (HRSA),
the Federal agency responsible for collecting, analyzing, and
disseminating health workforce information and facilitating national,
State and local workforce planning efforts.
As interest in integrative health care and the use of complementary
and alternative therapies by consumers has continued to grow, concern
has increased that health professionals be sufficiently informed about
integrative health that they can effectively care for patients. Among
various professional groups, debate continues as to what constitutes
sufficient information. Various national panels and commissions have
examined this issue and recommendations have emerged, some of which are
beginning to impact the education of health professions.
This paper will attempt to go beyond the current paradigm of
workforce planning and health professions education and will:
Review recommendations for curricular reform that have
emerged from the Institute of Medicine (IOM) panel on Health
Professions Education, the IOM Panel on Use of Complementary and
Alternative Medicine, the White House Commission on Complementary and
Alternative Medicine and the National Education Dialogue.
Summarize efforts by National Institutes of Health
National Center for Complementary and Alternative Medicine (NIH NCCAM)
to stimulate curricular reform in both conventional and CAM
institutions.
Examine the educational preparation and workforce
structure of representative CAM and biomedical professions and efforts
within the professions to make curricular changes that advance
integrative health care.
Review data on attitudes of health professionals toward
integrative health care, conventional medicine, and CAM.
Identify strategies impacting health professions education
including the development of competencies and interdisciplinary
education initiatives at the undergraduate and graduate level.
Discuss the implications of changing care models on
workforce needs and the focus and demand for health professions
training.
Offer recommendations that will advance integrative health
care and enable the United States to move from the current health care
system that is sporadic, reactive, disease-oriented and physician-
centric to one that fosters an emphasis on health, wellness, early
intervention for disease, patient empowerment, and focuses on the full
range of physical, mental, and social support needed to improve health
and minimize the burden of disease.
There are a number of different definitions of integrative health
and integrative medicine commonly used. The Bravewell Collaborative
(2008) describes integrative medicine as having the following
characteristics:
Patient-centered care and focuses on healing the whole
person--mind, body, and spirit in the context of community.
Educates and empowers people to be active participants in
their own care, and to take responsibility for their own health and
wellness.
Integrates the best of Western scientific medicine with a
broader understanding of the nature of illness, healing, and wellness.
Makes use of all appropriate therapeutic approaches and
evidence-based global medical modalities to achieve optimal health and
healing.
Encourages partnerships between the provider and patient,
and supports the individualization of care.
Creates a culture of wellness.
The Consortium of Academic Health Centers for Integrative Medicine
(2005), a consortium of 42 medical schools, offers the following
definition: ``Integrative medicine is the practice of medicine that
reaffirms the importance of the relationship between practitioner and
patient, focuses on the whole person, is informed by evidence, and
makes use of all appropriate therapeutic approaches, health care
professionals and disciplines to achieve optimal health and healing.''
Many health care providers who practice whole person, relationship-
based care that embodies the characteristics described in the above two
definitions do not identify their practice as being medicine-based,
viewing that word as focusing on the discipline of medicine. Boon et
al., (2004) describe integrative health care as an interdisciplinary,
nonhierarchical blending of both conventional and complementary and
alternative health care that provides a seamless continuum of
decisionmaking, patient-centered care, and support. According to Boon
and colleagues, integrative health care is based on a core set of
values, including the goals of treating the whole person, assisting the
innate healing properties of each person, and promoting health and
wellness and the prevention of disease. It employs an interdisciplinary
team approach that is guided by consensus building, mutual respect, and
a shared vision of health care. For the purposes of this paper,
integrative health care will be used to describe a healing oriented
approach that encompasses the above definitions. The term integrative
medicine will be used more narrowly when referring to the education and
practice of medical doctors. CAM is a term that is used to describe a
group of diverse medical and health care systems, practices and
products that are not considered to be part of conventional medicine.
CAM includes a wide variety of disciplines and practices, ranging from
licensed chiropractors, naturopathic physicians and traditional Chinese
medicine practitioners to yoga or meditation teachers. In this paper we
will distinguish between the licensed CAM fields and those that are
not.
CURRICULUM REFORM RECOMMENDATIONS
Over the past 10 years, several multidisciplinary national panels
including the IOM Committee on Health Professions Education, the IOM
Committee on Complementary and Alternative Medicine, the White House
Commission on Complementary and Alternative Medicine, and the National
Education Dialogue have made recommendations for specific reforms to
address some of the pressing problems in the education of health care
professionals. Recommendations have addressed some of the deficiencies
in cross-discipline understanding and communication which have
contributed to the ``quality chasm'' described by the IOM in 2001.
The IOM Committee on Health Professions Education (IOM, 2003),
although it did not specifically address the issue of integrating CAM
professions with ``conventional,'' put great emphasis on the need for
team-based, interdisciplinary educational strategies as a means to
reduce medical error and improve health care quality. The committee
stated as it's overarching vision for education of health
professionals, that ``all health professionals should be educated to
deliver patient-
centered care as members of an interdisciplinary team, emphasizing
evidence-based practice, quality improvement approaches, and
informatics.'' It also recommended that a set of shared competencies
across all health care professions, focused on patient-centered care,
be required by regulatory bodies governing education in the various
disciplines.
The IOM Committee on Complementary and Alternative Medicine
recommended that all conventional health professions training programs
incorporate sufficient information about CAM into the standard
curriculum to enable licensed professionals to competently advise their
patients about CAM (IOM, 2005). It did not specifically address the
need for CAM professionals to have basic information about the
conventional disciplines, but did stress the need for more research
training for the CAM professions as a way to bridge the gap in
communication between disciplines.
The White House Commission on CAM (2002) made several specific
recommendations regarding training, including the following:
The education and training of CAM and conventional
practitioners should be designed to ensure public safety, improve
health, and increase the availability of qualified and knowledgeable
CAM and conventional practitioners and enhance the collaboration among
them.
CAM and conventional education and training programs
should develop curricula and other methods to facilitate communication
and foster collaboration between CAM and conventional students,
practitioners, researchers, educators, institutions, and organizations.
Increased Federal, State, and private sector support
should be made available to expand and evaluate CAM faculty, curricula,
and program development at accredited CAM and conventional
institutions.
Finally, the report from the National Education Dialogue (NED), a
multidisciplinary group of educators from health care disciplines
including nursing, medicine, acupuncture and traditional Chinese
medicine, naturopathic medicine, chiropractic, and massage recommended
a process to identify and promote the development of interinstitutional
training relationships, stating that ``students educated in an
environment of mutual respect and collegiality among disciplines will
be more likely to practice collaborative health care'' (NED, 2005). The
proceedings of this meeting in 2005 included a survey documenting a
substantial degree of interest in interaction/exchange between medical
schools affiliated with the Consortium of Academic Health Centers for
Integrative Medicine (CAHCIM) and CAM schools. As noted by Weeks
(2006), approximately 85 percent of respondents from both medical and
CAM schools agreed that creating a fully integrated healthcare system
will require that institutions and programs develop stronger, multi-
dimensional, interinstitutional relationships with programs of the
other disciplines. Like the IOM Committee on Health Professions
Education, the NED participants recommended the development of a set of
shared competencies/values across disciplines which would ultimately be
required for every discipline and thus would lay the groundwork for
more effective collaboration.
NIH NCCAM R-25 GRANT PROGRAMS
The National Center for Complementary and Alternative Medicine
(NCCAM) was established in 1998 at the National Institutes of Health
(NIH) in response to public interest in complementary and alternative
medicine (CAM). Public Law 105-277 authorized NCCAM to conduct
scientific research, train researchers, and disseminate authoritative
information about CAM to the public and health professionals. In 1999,
NCCAM initiated a program called the Complementary and Alternative
Medicine Education Project, the goal of which was to incorporate CAM
information into the curriculum of selected health professions schools.
The details of this program are described in a recent article by
Pearson and Chesney (2007). Between 2000 and 2003, 14 schools in the
United States and the American Medical Students Association received
grants of up to $300,000 per year in direct costs with a maximum
duration of 5 years. Twelve grants were awarded to medical schools or
programs focused on education of more than one discipline and two were
awarded to schools of nursing. As noted by Pearson and Chesney, the
emerging goals from these CAM curriculum efforts were that conventional
health care providers, as part of an integrative health care
environment, would have sufficient knowledge and skills to:
Know how to ask patients about their use of CAM or
integrative medical practices.
Be familiar with the most commonly used forms of CAM so
they can discuss these practices with their patients.
Be able to refer interested patients to reliable sources
of information.
Know how to obtain reliable information about the safety
and efficacy of CAM or integrative medical practices.
The October 2007 issue of Academic Medicine was devoted to a series
of articles on the CAM Education Project grants. Detailed information
is available on the rationale and focus of student learning (Gaylord
and Mann, 2007; Gaster et al., 2007); organizational and instructional
strategies (Lee et al., 2007); barriers, strategies and lessons learned
(Sierpina et al., 2007); strategies to foster student self awareness
(Elder et al., 2007); evaluation of CAM education programs (Stratton et
al., 2007); and collaborative initiatives between allopathic and CAM
health professionals (Nedrow et al., 2007).
NCCAM initiated a second series of R-25 grants in 2004 that focused
on the goal of increasing research content in CAM practitioner programs
that offer a doctoral degree in a CAM practice. The CAM Practitioner
Research Education Project Grant Partnership required that a CAM school
partner with a research intensive university to develop curricula. The
major focus of curricular efforts is research literacy and the
integration of content on evidence-based or informed practice. Awards
were made to nine institutions that included institutions offering
chiropractic, naturopathic and TCM.
A common finding among all of the institutions awarded grants under
the R-25 program is that while these grants were titled curriculum
grants, at the core, the focus without exception has also been on
fostering culture change. This has required extensive faculty
development and it is widely acknowledged that change of this nature
takes significant time, requiring engagement of leadership, faculty,
and students.
HEALTH WORKFORCE STRUCTURE AND EDUCATION
Education of health professionals occurs in a wide variety of
public and private settings. Within some academic programs preparing
physicians and nurses, information on integrative health and medicine
is taught in required or elective curricula. Topics commonly addressed
include relationship-based care, whole person care (i.e. mind, body and
spirit), complementary and alternative medicine and self-care.
Organizations such as the CAHCIM, a consortium of 42 medical schools
with integrative medicine programs, and the NCCAM R-25 education grants
have accelerated curriculum innovation.
Integrative health care is also practiced by a number of
practitioners, often referred to as CAM practitioners. These
practitioners vary considerably in educational preparation, scope of
practice and licensure to such an extent that a generic term such as
CAM is not particularly descriptive or useful. Recently, the term
``natural medicine'' has been associated with educational programs in
licensed fields of chiropractic, naturopathic medicine, TCM and massage
therapy. While the major focus of these educational programs is content
related to the respective area of specialization, to varying extents,
information is also taught on self-care, whole person care, evidence-
based or informed practice, relationship-based care, and other aspects
of integrative health care. Content on interdisciplinary or team care
is generally not adequately addressed in either the CAM or conventional
health care educational institutions/programs.
In an effort to highlight the diversity and complexity of the U.S.
health care workforce and the opportunity that we face to advance the
health of the public by fully utilizing health professionals prepared
in integrative health care, we have chosen to profile two biomedical
professions (medicine and nursing) and four licensed disciplines in
natural medicine (chiropractic, naturopathic medicine, TCM and massage
therapy). While this is not an exhaustive review that includes all
biomedical and CAM disciplines, it is intended to be illustrative of
the strengths, weaknesses, challenges, and issues faced within health
professions education that both impede and advance integrative health
care.
Medicine
Medicine (also known as ``biomedicine,'' ``allopathic medicine,''
and ``conventional medicine'') is an approach to health care which
applies scientific principles and findings from medical research to
treat specific disease conditions and prevent illness. The most
commonly used strategies in conventional medicine involve the use of
pharmaceuticals, surgical procedures, and other technologically
advanced interventions. There is a strong belief in conventional
medicine that most, if not all, diseases can ultimately be determined
to have a physical cause, whether this cause is biochemical,
infectious, genetic, or traumatic. Influences of mind and spirit on
overall health have been generally not emphasized in medical training
and approach outside of the specialty of psychiatry, although this has
changed to some degree in the past two decades. Medical doctors trace
the history of their profession back to Hippocrates; however, the
current scientific approach to medicine really began in the late 19th
century.
Primary care physicians include family practitioners, internists,
pediatricians, and gynecologists, and are generally the first point of
contact for patients with the health care system and have an explicit
focus on prevention as well as treatment of disease. Specialists
including surgeons, dermatologists, physiatrists, radiologists, and
many others, typically focus on the application of a specific approach
to the treatment of disease. Subspecialists include cardiologists,
oncologists, gastroenterologists, and many other disciplines generally
focused on the diagnosis and treatment of dysfunction in one specific
organ or organ system.
Medical doctors must graduate from an accredited medical school and
pass a licensing exam given by the U.S. Medical Licensing Examination
(USMLE). There are 130 accredited medical schools currently in the
United States. The curriculum includes courses in anatomy,
biochemistry, pharmacology, physiology, and genetics, and medical
doctors in training must complete ``rotations'' in the major
disciplines including medicine, pediatrics, psychiatry, surgery,
obstetrics/gynecology, and family practice prior to graduation from
medical school. After 1 year of postgraduate training they may apply
for a license in their State; licensing is State-specific and medical
doctors must apply for licensing in each State in which they wish to
practice. Board certification in a given specialty requires completion
of an accredited residency in that specialty; residency programs can
range in length from 3-7 years. Board certification also requires
passing an exam developed by a specialty recognized by the American
Board of Medical Specialties. At this point, many specialties require
recertification at intervals of 7-10 years. Subspecialty certification
generally requires an additional 1 to 3 years of fellowship training.
As of 2006, there were approximately 633,000 physicians employed in
the United States (U.S. Department of Labor, 2008). The American
Medical Association data from 2005 show that approximately 40 percent
of physicians were in a primary care specialty, and 60 percent in
subspecialties (American Medical Association, 2007). Data suggest that
some geographic areas have significant shortages of primary care
physicians (Fryer et al., 2004). Historical data also show that major
health outcomes including all-cause mortality, cancer, heart disease,
stroke, and infant mortality; low-birth weight; and life expectancy are
significantly better in areas with adequate access to primary care
(Macincko et al., 2007; Starfield et al., 2005). The concept of the
``medical home,'' currently gaining momentum in the health care system
is based on this data regarding the importance of an identified source
of primary care. To date, no data definitively suggest that this
primary care must be delivered by a medical doctor.
Services of medical doctors are generally reimbursed by insurance
companies. In recent years, due to delays in payments from insurers and
inadequate reimbursement levels, many physicians have begun to ``opt-
out'' of insurance plans. This has compounded the problems with access
to medical care created by the large percentage of uninsured in the
U.S. population.
Since the publication of Eisenberg's work documenting the extent of
use of CAM in the U.S. population (Eisenberg, 1998), there has been a
movement to incorporate basic knowledge on CAM into conventional
medical education. As of 2003, 98 of 126 U.S. medical schools have
incorporated at least some teaching on CAM into their curricula
(Barzansky and Etzel, 2003). However, many of these offerings were
elective rather than required, and the true impact of these curriculum
offerings on attitudes and practices of physicians has not been
systematically evaluated.
The first set of published guidelines on CAM in conventional
medical education curriculum was developed for residency-level training
by the Society of Teachers of Family Medicine in 2000 (Kligler et al.,
2000). Of all the medical specialties, family medicine as a
discipline--perhaps because of its basis in the biopsychosocial model
and the ``whole person'' perspective that engenders--has been the most
open to exploring new strategies to teach trainees about integrative
approaches. Post-graduate level training in family medicine--both at
the residency and fellowship levels--has proved a relatively receptive
environment for integrative medicine training programs. An exciting
recent development, spearheaded by the Center for Integrative Medicine
at the University of Arizona, is the Integrative Medicine in Residency
program (IMR). The IMR is a 250-hour internet-based curriculum in
integrative medicine designed for family medicine and other primary
care residents which is currently being piloted for feasibility and
effectiveness at eight residency programs around the country.
The IMR program grew out of another important innovation, again led
by the Arizona Center: the Integrative Family Medicine program. This
program, which combines fellowship level training in integrative
medicine with family medicine residency training, has been running at
six residency sites since 2003, and has trained over 30 fellows (Maizes
et al., 2006). The IFM has been an excellent laboratory to develop
educational strategies as well as competency-based evaluation tools for
the incorporation of CAM training into conventional medical post-
graduate education (Kligler et al., 2007).
Another development on the post-graduate national landscape was the
formation of the American Board of Integrative Holistic Medicine
(ABIHM), which was formed in 1996 as an independent credentialing body
for physicians in this field. Although ABIHM is not recognized by the
American Board of Medical Specialties and therefore does not represent
an ``official'' board certification in the eyes of orthodox medicine,
it does represent a serious effort to establish standards for
certification in this area for physicians. To date 1,040 physicians
have received ABIHM Diplomate designation.
Although many medical schools now offer at least elective courses
in CAM and integrative health care, undergraduate medical education has
been a more difficult challenge for integrative medicine educators.
Over the past 6 years CAHCIM has been very active in trying to promote
curriculum reform and to move towards goals outlined by the previous
IOM committees, the White House Commission, and the NED process. In
2004, a set of consensus guidelines for undergraduate medical education
in integrative medicine was published in Academic Medicine (Kligler et
al., 2004). This document, a collaborative effort between educators at
13 medical schools, incorporated a set of core values critical to
education in integrative medicine as well as a set of knowledge,
skills, and attitudes. Although this document provides a useful set of
tools for educators, to date its curriculum recommendations have not
been widely implemented.
A recent small step forward resulted from an exchange between
CAHCIM and the Liaison Committee on Medical Education (LCME), the
accrediting organization for U.S. medical schools. CAHCIM proposed
specific changes to 3 LCME Educational Accreditation Standards, with
the aim of more explicitly requiring medical schools to include
teaching on integrative medicine in their required curriculum. The
proposed changes would have incorporated modifications into the
mandated educational standards regarding multidisciplinary content
areas, communication skills, and cultural competence--all areas in
which education in integrative health care would naturally fit.
Although the LCME did not agree to revise any standards, it did take a
step forward by adding the topic of ``complementary and alternative
health care'' to the list of topics addressed in the LCME Medical
Education Database relative to accreditation standard ED-10 for schools
anticipating survey visits scheduled for 2009-2010 and thereafter.
(LCME, 2008) This educational standard mandates the inclusion of
behavioral and social sciences in the curriculum, and details a list of
subjects in this area considered important for physicians. As part of
the LCME survey (LCME Part II Annual Medical School Questionnaire),
schools will now be asked to identify where in their curriculum CAM is
covered (required vs. elective course or clerkship) and how many
sessions are dedicated to this topic.
This change in LCME policy represents progress; however, it falls
short in that it still does not specifically mandate required exposure
to CAM or integrative health care. The recommendation as it stands does
not ensure achievement of the recent IOM recommendation for physicians
to emerge from training ``competent to advise'' patients on CAM. As
such, further steps by the LCME mandating required coverage of this
area in the medical school curriculum will be needed if we are to reach
this outcome.
Nursing
While the role of nurses, their educational preparation, and the
settings in which they practice have evolved over time, the focus of
nursing has remained fairly constant. Florence Nightingale, the founder
of modern nursing, described the work of the nurse as helping the
patient attain the best possible condition so that nature could act and
self-healing could occur (Dossey, 2000). The focus of the art and
science of nursing goes beyond fixing or curing to ease the edges of
patients' suffering, to helping them to restore function, maintaining
patient health, aiding those living with chronic illness, or supporting
patients through a peaceful death. Nurses are experts in symptom
management, care coordination, health promotion and chronic disease
management. In addition to caring for people from birth to death, they
are also prepared to plan and manage care for communities, conduct
research, manage health systems and address health policy issues.
Much of what is now called CAM or complementary therapies has
fallen within the domain of nursing for centuries. Nurses are educated
to be holistic practitioners--attentive to the whole person, the mind,
body and spirit. Academic programs in nursing routinely include
information on massage, music, imagery, energy healing, meditation and
relaxation therapies, and use of essential oils.
Nurses constitute the largest group of health care professionals in
the Nation. They are academically prepared in several ways. Nurses
educated in 2-year associate degree or 3-year diploma program are
eligible for registered nurse (RN) licensure and most commonly work in
hospitals, long-term care facilities and out-patient (clinic) settings.
Baccalaureate prepared nurses or nurses who attain entry into practice
in accelerated MA programs are also eligible for RN licensure and work
in public health as well as the settings noted above. They are also
more likely to assume leadership roles. Two agencies provide
accreditation to nursing programs: the Commission on Collegiate Nursing
Education (CCNE) and the National League for Nursing Accrediting
Commission (NLNAC). CCNE accredits baccalaureate and graduate education
programs. NLNAC accredits diploma, associate, baccalaureate and
master's degree nursing programs. State licensing authorities regulate
entry into the practice of nursing. Candidates for licensure as an RN
are required to pass the National Council Licensure Examination--
Registered Nurse (NCLEX-RN) exam developed by the National Council of
State Boards of Nursing (NCSBN).
The nurse practitioner (NP) role emerged in the mid-1960s as a
cost-effective approach to address the Nation's primary care needs
during an era of projected physician shortages. NPs complete a graduate
level education program that prepares them for practice in their area
of specialty and are licensed independent practitioners. NPs provide
primary care in a wide variety of settings including adult health,
pediatrics, family, gerontological, and women's health care. NPs are
also prepared in specialty areas such as mental health, neonatal care
and acute care. They are prepared to diagnose and treat patients with
undifferentiated symptoms as well as those with established diagnoses.
NPs provide initial, ongoing, and comprehensive care that includes
taking health histories, providing physical examinations and other
health assessment and screening activities, and diagnosing, treating,
and managing patients with acute and chronic illnesses. This includes
ordering, performing, supervising, and interpreting laboratory and
imaging studies; prescribing medication and durable medical equipment;
and making appropriate referrals for patients and families. NPs have
prescriptive authority in all States. The scope of practice of NPs
includes health promotion, disease prevention, health education, and
counseling as well as the diagnosis and management of acute and chronic
diseases. It is estimated that NPs can effectively manage 80 percent of
patients' primary care needs. In two meta-analyses (Brown and Grimes,
1995; Horrocks et al., 2002) of over 35 studies, comparable care
outcomes were attained by M.D.s and NPs. The most recent Health
Resources and Services Administration (HRSA) Survey report (2005)
estimates 141,209 nurse practitioners in the United States, an increase
of more than 27 percent over 2000 data. The actual number of nurse
practitioners in 2006 is estimated by the American College of Nurse
Practitioners (2008) to be at least 145,000.
A report on competencies of nurse practitioners in primary care
settings prepared for HRSA in 2002 by the National Organization of
Nurse Practitioner Faculties (NONPF) and American Association of
Colleges of Nursing (AACN) (2002), contains no explicit reference to
content on integrative health/medicine. However, a survey by Burman
(2003) of family nurse practitioner program directors found that 98.5
percent of the 141 respondents reported that their FNP programs
included CAM-related content and that 83 percent integrated CAM content
into existing courses.
Certified nurse-midwifes (CNMs) provide a full range of primary
health care services to women throughout the lifespan, including
gynecologic care, family planning services, preconception care,
prenatal and postpartum care, childbirth, and care of the newborn. Like
NPs, CNMs are nurses with graduate preparation and are licensed,
independent practitioners who have prescriptive authority. Nurse-
midwives provide care in many settings including hospitals, birth
centers, and a variety of ambulatory care settings including private
offices, community and public health clinics and homes. A recent
Cochrane review (Hatem et al., 2008) of 11 trials (12,276 women) found
that women who had midwife-led models of care were less likely to
experience antenatal hospitalization, regional anesthesia, episiotomy,
and instrumental delivery and were more likely to experience
spontaneous vaginal birth and initiate breastfeeding. Women randomized
to receive midwife-led care were less likely to experience fetal loss
before 24 weeks gestation and their babies were more likely to have a
shorter length of hospital stay. The review concluded that all women
should be offered midwife-led models of care and should be encouraged
to ask for this option. The American College of Nurse Midwives (2007)
in a document titled Core Competencies for Basic Mid-wifery Practice,
describes the evaluation and incorporation of complementary and
alternative therapies in education and practice as a hallmark of mid-
wifery practice in all settings for mid-wifery care including
hospitals, ambulatory care settings, birth centers and home.
NPs and nurse-midwives are advanced practice registered nurses
(APRNs), as are nurse anesthetists and clinical nurse specialists.
APRNs attain certification in their specialty and practice within
standards established or recognized by professional associations and
licensing bodies. Currently, no uniform model of APRN regulation exists
across the States. Each State independently determines the APRN legal
scope of practice, the roles that are recognized, the criteria for
entry-into advanced practice, and the certification examinations
accepted for entry-level competence assessment. This has created a
significant barrier for APRNs to easily move from State to State. The
graduate preparation for APRNs has historically been a master's degree.
Over the past 5 years, there has been a transition to a clinical
doctorate degree, the doctorate of nursing practice (DNP).
Integration of content on integrative health/medicine into other
graduate nursing programs varies considerably. Many graduate programs
in nursing teach content on integrative health/medicine as it relates
to health promotion, lifestyle coaching, and disease management. A more
recent trend has been to develop graduate programs in nursing that have
integrative health as a major area of emphasis. The University of
Portland offers a DNP program with a Family Nurse Practitioner
specialty that includes emphasis on integrative health. New York
University College of Nursing offers a masters level adult holistic
health nurse practitioner program. At the University of Minnesota
School of Nursing, integrative health is integrated into all 14 DNP
specialty programs including adult health, women's health, midwifery,
and public health. Additionally, a DNP in Integrative Health and
Healing was developed to prepare practitioners and leaders who can work
within a wide variety of clinical settings with diverse patient
populations and provide leadership within organizations.
Nurses prepared at the Ph.D. level are skilled in conducting
research. As integrative health care becomes a more visible and
prominent area of focus within nursing programs, it is anticipated that
doctorally prepared faculty and clinicians will contribute to the
evidence-base of CAM and integrative health care.
According to the American Association of Colleges of Nursing (AACN)
(2008), the United States has a severe nursing shortage that is
expected to intensify as the need to health care grows with the aging
of the baby boomers and as the need for health care grows. The shortage
of RNs could reach 500,000 by 2025. Nursing colleges and universities
are struggling to expand enrollment levels to meet the rising demand
for nursing care, a situation made more challenging by a shortage of
nursing faculty.
Chiropractic
Chiropractic is a 113-year-old primary (first contact) health care
profession that developed in the U.S. Chiropractic practitioners focus
on the neuromusculoskeletal system, especially the spine, to manage
related conditions and to enhance general health and wellness. Surveys
have found that chiropractic care is used overwhelmingly by patients
with pain complaints related to joints, muscles and other somatic
tissues, though a significant fraction of patients also use
chiropractic care to enhance their well-being and quality of life
(Meeker and Haldeman, 2002). Doctors of Chiropractic (DC), by statute
and choice, generally practice a drugs-free hands-on approach that
includes the full range of standard case-management behaviors including
the application of broad diagnostic responsibilities and skills.
Chiropractors are well-known as experts in the biomechanical science
and art of manual manipulative procedures known as ``chiropractic
adjustments'' but they are trained to recommend therapeutic and
rehabilitative exercises, as well as provide nutritional, dietary and
lifestyle counseling. DCs are trained to work well with other
professionals when patients' needs can most benefit from a coordinated
approach, and to refer to medical specialists as appropriate.
Approximately 70,000 licensed DCs in the United States handle over
190 million visits annually, providing care to an estimated 7-10
percent of the population, which compares favorably with the
approximately 380 million visits made to primary medical care providers
(Eisenberg et al., 1998). Chiropractors are concentrated in urban
areas, but some also serve as the only primary health care providers in
rural medically-underserved areas (Smith and Carber, 2002). The
profession experienced considerable growth through the mid-1990s, but
this has slowed to modest growth projections through the next decade.
However, the profession is expanding at a strong rate outside of North
America.
The profession of chiropractic began in Iowa in 1895 when D.D.
Palmer coined the word to describe a theory of health and disease that
incorporated spinal manipulation as a major part of the approach. Forms
of joint and soft tissue manipulation have been components of
traditional treatments dating back thousands of years, but Palmer
claimed to have perfected the art and professionalized the practice. He
established the Palmer College of Chiropractic in 1897, the largest and
oldest chiropractic institution in the world. Over the course of the
next 7 decades, chiropractic became a legally licensed profession one
State at a time, often experiencing considerable political resistance
from conventional medicine (Meeker and Haldeman, 2002).
Effective political lobbying and patient support caused Medicare to
begin limited reimbursements for chiropractic care in the early 1970s.
Around the same time, chiropractic education was officially accredited
by the U.S. Department of Education through the Council on Chiropractic
Education (CCE). In 1987, the profession won a decade-long legal battle
against the American Medical Association for antitrust violations. In
1994, HRSA began to fund chiropractic institutions to conduct research,
which was followed in 1997 with significant center grant funding by NIH
NCCAM. Chiropractic scientists were appointed to serve on NCCAM's
National Advisory Committee, on NIH study sections, and on other
policymaking bodies.
Practitioners, scientists and policymakers have become increasingly
aware that a reasonable body of credible scientific evidence was
accumulating concerning the benefits of spinal manipulation for spine-
related pain (Bronfort et al., 2008; Chou et al., 2007), a major public
health concern (Dagenais et al., 2008). This was initially codified in
a clinical guideline published by the U.S. Agency for Health Care
Policy and Research in 1994 (Bigos et al., 1994). Within the past
decade, chiropractors have been officially positioned in the Veteran's
Health Administration and Department of Defense facilities.
Chiropractic is now so widely acknowledged and used by the public for
spine-related conditions and embedded in some standard health delivery
and reimbursement systems, that it can be characterized as standing at
the ``crossroads between alternative and mainstream medicine'' (Meeker
and Haldeman, 2002).
Philosophically, chiropractic is based on the premise that the body
contains an ``innate'' healing ability, and that a drugs-free, hands-on
``natural'' approach best enhances this healing response. The emphasis
tends to be on wellness and quality of life, working with patients'
environments and motivations to reach the highest level possible of
pain-free function. The ``personality'' of chiropractic care leads to
very strong doctor patient relationships, which have been described in
many studies noting high levels of patient satisfaction (Cherkin and
MacCornack, 1989; Carey et al., 1995). Strong support by patients has
probably contributed to chiropractic's current position as the most
widely utilized profession-based ``CAM'' practice in the United States.
Chiropractors are licensed and accordingly regulated in all States
after the completion of what is typically a 4-5 year academic program
conferring the DC degree, and the passing of a 4-part progressive
standardized set of didactic and practical examinations administered by
the National Board of Chiropractic Examiners, the principal testing
agency for the profession. Most States require annual continuing
education credits to maintain licensure. DCs are now recognized in most
public and private reimbursement systems and within the past decade the
profession's institutions have begun to be included in some Federal
programs as potential recipients of programmatic support for education,
practice, and research.
Currently, 17 chiropractic training institutions in the United
States are accredited by the CCE. All but two colleges are also
accredited by regional accrediting bodies as well. Most are free-
standing, non-profit organizations but at least two are programs
contained within larger colleges or universities. During the past
decade, at least four chiropractic institutions have also initiated or
incorporated training programs for other types of CAM practitioners
such as massage, acupuncture, and naturopathy. Students entering
chiropractic programs must have successfully completed at least 90
credit hours (3 years) of undergraduate coursework that must include
specific hours in basic sciences and humanities. Approximately 75
percent of entering students have baccalaureate degrees. The DC
curriculum of 4,200 minimum hours is similar to a medical school
curriculum but emphasizes neuromusculoskeletal conditions and
biomechanical interventions over pharmacology. Chiropractic
institutions are increasingly embracing the evidence-based care
paradigm of making clinical decisions based on best available
scientific evidence, clinical experience, and patient preferences.
Practical experience is required in public teaching clinics as opposed
to hospital internships. National board exams are required at specified
points during the educational journey, and are necessary for final
State licensure as described above. Post-graduate specialty
certification is available in radiology, rehabilitation, sports,
nutrition, pediatrics, orthopedics, neurology, and others, usually
after the completion of courses, a residency, and a standardized
examination.
Chiropractic has the most highly developed educational system of
the four licensed CAM professions in the United States being profiled
in this paper. The most visible current reform efforts are being driven
by the accrediting body, the CCE, and by recent educational program
grants (R-25) awarded by NCCAM to 4 schools to increase scientific
content and critical thinking skills in the curricula. In all schools
there is a general movement to increase training in evidence-based
practice (EBP) concepts and to incorporate the knowledge, attitudes,
and skills of EBP into the clinical component of the education. In
concert with evolving educational practices, there is a growing
institutional emphasis on institutional assessment of learning
outcomes. Chiropractic institutions have nurtured a scholarly community
that meets annually under the auspices of the Association of
Chiropractic Colleges to share data, programs and experience.
Educational research is published in the Journal of Chiropractic
Education.
While not directly related to integrative health care goals, the
advent of federally funded basic and clinical research grant awards to
chiropractic institutions starting in the 1990s has contributed
significantly to the evolution of the nascent scholarly culture. During
the past decade, the government awarded approximately $40 million to
support chiropractic-related research, much of it in projects requiring
scientific collaborations with established universities. The Journal of
Manipulative and Physiological Therapeutics, the premier research
journal of the profession, dates back to 1978, and is widely regarded
in the generic physical medicine community. Faculty development is now
receiving special attention as never before. For example, the Palmer
Center for Chiropractic Research received a K-30 NIH grant in 2001 to
establish a Master of Clinical Research degree to train chiropractors
to conduct high quality clinical research, and has been successful in
placing graduates in scholarly positions. In addition, Palmer recently
established the Center for Teaching and Learning for its three campuses
to develop and execute focused faculty development efforts using
emerging educational technologies. With regard to interdisciplinary
training and experience, the majority of chiropractic institutions
either have or are in the process of developing clinical rotation
opportunities at Veteran's Health Administration hospitals and
Department of Defense facilities that employ chiropractors. Further
efforts are being made to incorporate newly graduated chiropractors in
loan-repayment programs that reward service in community health
clinics. While these arrangements are currently few in number, the
clinical experience to be gained from working in integrated health care
settings has obvious implications for students as they subsequently
move along in their careers, and underscores the need to develop
didactic interdisciplinary objectives.
Traditional Chinese Medicine
Chinese medicine is an ancient healing tradition dating back almost
3,000 years. Its core components are acupuncture, Chinese herbal
medicine, moxibustion, massage (or body-work), and exercise and
lifestyle/nutrition recommendations. Acupuncture is most widely known
in the United States, but the majority of licensed acupuncturists also
use Chinese herbs and other approaches. The philosophy of Chinese
medicine revolves around the modulation of the flow of Qi (life energy)
through a system of channels in the body. Most States of illness or
imbalance can be traced to disorders in the flow of Qi, and correcting
these can help restore health and prevent illness. According to the
2002 National Health Interview Survey, as of 2002, approximately 8.2
million U.S. adults had used acupuncture, and an estimated 2.1 million
U.S. adults had done so in the previous year (Barnes et al., 2004).
Forty-three States plus Washington, DC regulate and license
acupuncturists. The scope of practice varies by State. Most States
require the passage of the National Certification Commission for
Acupuncture and Oriental Medicine exam, although California has its own
exam. The entry level degree for the field is a master's degree.
Currently, there are three main degrees offered in the acupuncture/
Oriental medicine educational institutions: the master's in acupuncture
(3 years); the master's in acupuncture and Oriental medicine (4 years);
and the Doctorate in Acupuncture and Oriental Medicine (DAOM) (an
additional 2 years following the masters's degree). As a general rule,
physician acupuncturists undergo significantly less training (300 hours
on average) than those with master's or doctoral degrees in acupuncture
and oriental medicine.
A qualifying exam that is used by most States as a component for
licensure has been administered by the National Certification
Commission for Acupuncture and Oriental Medicine (NCCAOM) since 1985,
and to date over 19,000 certificates have been granted in Acupuncture,
Oriental Medicine, Chinese Herbology, and Asian Bodywork Therapy, the
four categories in which the NCCAOM examines for qualification (NCCAOM,
2008). To be eligible for NCCAOM certification, one must graduate from
a master's or doctoral level program accredited by the Accreditation
Commission for Acupuncture and Oriental Medicine (ACAOM), the agency
designated by the U.S. Department of Education to set standards in this
area. Currently over 60 schools and colleges are either accredited or
have candidacy status with the ACAOM (ACAOM 2008). To be accredited, an
acupuncture program must be at least 3 years in length, and include
core subjects such as history and theory of Oriental medicine,
acupuncture point location, diagnostic skills, treatment techniques,
and biomedical clinical sciences. The Acupuncture and Oriental Medicine
master's degree must be at least 4 years in length and include Chinese
herbology. The clinical Doctorate in Acupuncture and Oriental Medicine
(DAOM) must be a total (including the master's degree) of 4,000 hours.
There are currently eight AOM colleges offering the DAOM clinical
doctoral degree.
Because different dimensions of Chinese medicine are practiced by
practitioners in these varying categories, establishing exact estimates
of the number of Chinese medicine practitioners or acupuncturists in
the U.S. workforce is extremely difficult. Estimates of the number of
licensed acupuncturists currently practicing in the United States range
from 25,000 to 30,000; the number of physician acupuncturists is
estimated at 3,000-6,000.
Although Chinese medicine has been practiced in Asian communities
in the United States since the 1850's, its widespread availability in
the United States has developed since 1970, when China opened to the
West. Many different styles of Chinese medicine are currently practiced
in the United States. Perhaps most widespread is TCM, a modified system
developed in the 1950s which combines a heavier reliance on herbal
medicines in combination with acupuncture. Classical Chinese medicine,
the dominant system until the emergence of TCM under Mao, relies more
on the use of acupuncture channels. Various other approaches have
developed elsewhere in Asia and Europe and are now practiced in the
United States as well, including Japanese acupuncture, Korean hand
acupuncture, five element theory, auricular acupuncture, and others.
A large body of clinical research now exists supporting the
effectiveness of acupuncture for a wide variety of clinical conditions.
The most extensively studied applications are in pain conditions: for
example, a Cochrane review of 35 randomized controlled trials (RCT)
covering 2,861 patients with chronic low-back pain concluded in 2005
that acupuncture is more effective for pain relief than no treatment or
sham treatment, in measurements taken up to 3 months (Furlan et al.,
2005). Recently, a large NIH-funded clinical trial showed acupuncture
to be effective in treating osteoarthritis of the knee (Berman et al.,
2004). In clinical practice, acupuncture is also widely used for
conditions for which clinical evidence is somewhat less definitive,
including treatment of allergies, asthma, and infertility.
TCM institutions have been generally more internally focused on
basic educational reforms and issues within the discipline than on
integrative health care goals. The diversity of TCM institutions and
inconsistent scope and licensing laws in the United States demand a
great deal of attention from TCM leaders. Steady progress has been made
however. Accreditation standards now mandate that doctoral level
students work collaboratively with other types of health care providers
in a variety of settings including hospitals. For example, many TCM
programs have developed high-level training relationships with TCM
hospitals in China. Typically, TCM students in the last stage of
training may spend 1 month or more observing and treating patients in a
multidisciplinary setting. There is growing interest in evidence-based
concepts and some TCM institutions have been awarded a number of
educational and research grants from NCCAM. In most cases, these
efforts also required collaborations with established university
scientists.
A new and exciting development is the emergence of post-graduate
fellowship programs for licensed acupuncturists seeking to gain more
experience in conventional health settings. Beth Israel Medical Center
in New York recently launched the first such program in the United
States, and eight graduate-level acupuncturists are now working and
training for 1 year in the hospital setting. As TCM moves towards a
doctoral-level degree for licensing on a national level, it is likely
that such interdisciplinary clinical training will become more
commonplace.
Naturopathic Medicine
Naturopathic medicine is a comprehensive system of primary health
care emphasizing prevention, treatment, and the promotion of optimal
health through the use of therapeutic methods and modalities that
encourage the self-healing process. It is a holistic approach to health
care that seeks to respect the unique individuality of each person.
Founded in the United States in 1902, naturopathic medicine
achieved its first regulation as a licensed practice within a decade.
The profession declined in the mid-century, only to begin a period of
renewal in the late 1970s when a new generation began to seek a
science-based education which would prepare them to be licensed with a
broad scope as general practitioners of natural medicine. The
educational, research, professional and regulatory infrastructure for
the present naturopathic profession was significantly reformed in this
modern era.
A naturopathic physician (ND) must complete a bachelor's degree
with premedical training before entering naturopathic medical school.
Naturopathic medical education is a 4-year graduate level training
program. Education in the first 2 years includes a basic science
curriculum very similar to M.D. education. Course work includes
anatomy, biochemistry, microbiology, physiology, embryology, histology
and genetics. Students complete additional courses in clinical
diagnosis, pathology, lab diagnosis and diagnostic imaging as well as
naturopathic philosophy and therapeutics, nutrition, mind-body
medicine, homeopathy and botanical medicine. In the final 2 years,
didactic education builds on naturopathic therapeutics and additional
coursework is completed in pediatrics, gynecology, gastroenterology,
orthopedics, cardiovascular health, disorders of the eyes, ears, nose
and throat, nephrology and dermatology. The focus is on clinical
sciences and supervised clinical instruction through teaching clinics
and externships in community locations.
This educational program is based on standards of the Council on
Naturopathic Medical Education (CNME), which gained recognition as an
approved accrediting agency by the U.S. Department of Education in
1987. Within North America, there are seven naturopathic medical
schools that have programmatic accreditation or candidacy status with
the CNME, five of these are in the United States. Each U.S. institution
is also accredited by, or is in candidate status for accreditation with
one of the regional accrediting agencies approved by the U.S.
Department of Education.
The seven CNME-recognized schools are also members of the
Association of Accredited Naturopathic Medical Colleges (AANMC). In
2007, the AANMC published a report on educational competencies. The
report delineated knowledge, skills and attitudes around 5 key roles
for the naturopathic physician:
The medical expert, who integrates naturopathic principles
and philosophy to reach accurate diagnoses and formulate safe,
effective treatment plans, manage patient care and interact with other
healthcare professionals for patients' benefit.
The naturopathic manager, who can create, develop and
maintain a clinical practice. Courses in practice management, ethics
and jurisprudence together with clinical training provide students with
the necessary experience and knowledge to succeed in this endeavor.
The naturopathic professional, who is well-grounded in the
history of the profession, understands the importance of ethical
practice, public health and participation in professional affairs on a
State and national level.
The naturopathic health scholar, who practices docere, the
role of doctor as teacher with individual patients and in the wider
community and who stays current through continuing medical education
and reading and critically evaluating the peer-reviewed literature.
The naturopathic health advocate, who practices prevention
with patients, understands and promotes the relationship of
environmental sustainability to human health, and participates in the
broader health care dialog.
To attain licensure, naturopathic physicians are required to
graduate from a CNME recognized program and then pass the Naturopathic
Physicians Licensing Examination Board (NPLEX). The board examination
is offered by the North American Board of Naturopathic Examiners
(NABNE) and is utilized by all of the States licensing naturopathic
doctors. To maintain licensure, NDs are required to fulfill State-
mandated continuing education requirements annually, and to practice
within the specific scope of practice defined by their State's law.
Naturopathic physicians are currently licensed in 15 States, as
well as the District of Columbia, and the United States territories of
Puerto Rico and the United States Virgin Islands. Expanding licensing
is a priority of the profession. California was added in 2004 and
Minnesota in 2008. The scope of practice of licensed naturopathic
physicians varies from State to State. In all States with updated or
laws, licensed members of the profession have prescriptive authority
for conventional pharmaceuticals, although the breadth of the formulary
varies. Variation between States also exists in such areas as rights to
use injections, the question of whether ``physician'' is a legal term,
the practice of natural childbirth and minor surgery, and inclusion of
acupuncture. Licensing efforts are underway in New York, Massachusetts,
Illinois, Florida and elsewhere.
The size of the naturopathic medical workforce has increased
significantly in the modern era, and particularly the past decade.
According to a 2001 report issued by the Center for Health Professions
at UCSF (Hough et al., 2001), there were approximately 1,300
naturopathic physicians licensed in the United States. The number of
licensed NDs has more than tripled in the past 10 years and the
American Association of Naturopathic Physicians (AANP) now estimates
that there are 3,500 licensed NDs across the United States. Roughly 400
new NDs graduate each year.
The AANP estimates that approximately 50 percent of NDs provide
primary care in office-based, private practice as solo practitioners.
NDs with less than 10 years of experience are more likely to practice
in interdisciplinary group practices. (Howard, 2008).
Insurance coverage varies by plan, and by jurisdiction. Connecticut
and Vermont have coverage mandates which in Vermont, beginning in 2007,
also included Medicaid. The ``every category of provider statute'' in
Washington State requires that all of that State's plans, beginning in
1996, had to include naturopathic physicians. In some plans, members
can choose naturopathic physicians as their primary care providers.
Because naturopathic physicians in Washington do not have the right to
admit patients to hospitals, the NDs in that State must have a
collaborative relationship with an M.D. to manage admissions.
Clinical research into natural therapies has become an increasingly
important focus for naturopathic physicians. Investigators at
naturopathic medical schools have been the recipients of NIH grants and
NIH NCCAM funded a project that led to the development of a research
agenda (Standish et al., 2006) that identified four strategic
priorities:
High validity randomized controlled trials (RCTs) of whole
practice naturopathic medicine;
Basic science including mechanism of action;
Health services research through regional demonstration
projects; and
Exploration of naturopathic medical principles through
basic and applied research.
The level of integration of naturopathic physicians with the
conventional healthcare system varies from State to State and is in
part, a function of the legally defined scope of practice and inclusion
by third party payers. In States where the relationship has had a
chance to mature, naturopathic professional activities are known to
include: creation of school-based health clinics; employment in
community health clinics; recognition as a primary care provider (PCP)
option in leading plans; participation in a State-funded student loan-
payback program for providing primary care to underserved communities;
collaboration on research, education and practice with conventional
academic health centers; participation with multidisciplinary consortia
of educators; employment as staff physicians or as specialists in
cancer centers and other specialty clinics; service on boards of
hospitals and public health agencies; and ongoing participation,
through actions of the professional associations, in diverse State and
local policy venues as part of the primary care matrix.
Massage Therapy
Massage therapy is an umbrella term covering a very wide range of
manual procedures targeting the body's soft tissues, primarily muscles,
with the intent of improving health. There is a notable lack of
consistency in the legal definition and scope of massage therapy, but
most jurisdictions agree that massage therapy excludes diagnosis; drug
prescription; manipulation or adjustments of the skeletal structure; or
any other service, procedure or therapy which requires a license to
practice orthopedics, physical therapy, podiatry, chiropractic,
osteopathy, psychotherapy, acupuncture, or any other profession or
branch of medicine.
Massage can be delivered as a relaxation procedure to reduce stress
and enhance well-being, or it can be used to address a variety of
health complaints such as musculoskeletal pain, headache, and anxiety.
At least 80 types of massage therapy exist including Swedish massage,
trigger point massage, deep tissue massage, and sports massage. There
are also many forms of massage from Asian cultures, notably Shiatsu,
Thai massage and acupressure. Most therapists specialize in a few
techniques.
Massage is a popular procedure delivered by practitioners in a
variety of private and professional settings, including hospitals,
medical spas and chiropractic offices. According to the American
Massage Therapy Association (AMTA) Web site (2008), typical massage
therapy sessions run 30-60 minutes. Estimates vary, but the 2007 AMTA
Consumer Survey results show that 24 percent of American adults had a
massage at least once in the preceding 12 months. AMTA further
estimates that there are 265,000 to 300,000 massage therapists and
students in the United States, and that employment for massage
therapists will increase by 20 percent between 2006 and 2016. Most
therapists are female (85 percent) and enter it as a second career (76
percent) in their early 40s, although increasingly, younger people are
beginning to enter the field as a first career. Therapists practice an
average of 19 hours per week and work in the field for about 7 years.
Because of the chaotic regulatory environment, health services data on
the relative rates of reimbursement are rough estimates at best. Most
massage practice is cash-based, but is being increasingly reimbursed by
many health plans and third party payors.
Massage is an empirical health care practice that dates back to
before recorded history. The overarching philosophical approach,
according to one well-regarded textbook, encompasses concepts of
natural healing, a holistic view of human life, and an innate healing
ability of the body (Benjamin, 2005). Massage therapists would describe
themselves as highly service-oriented practitioners who believe in
their ability to enhance their clients' well-being. Modern western-
style massage practice is usually linked to the work of Per Henrik Ling
(1776-1839) and Johann Georg Mezger (1838-1909), which came to be known
as Swedish massage around the turn of the century.
It is only in the past few decades that massage therapy has begun
to take on the characteristics of a health profession. State-level
licensing laws are being passed, such as in California where, until
recently, massage was regulated (or not) by local jurisdictions only,
creating an inconsistent and incoherent practice environment. Today, 39
States and the District of Columbia have passed laws regulating massage
therapy. In the States that have regulations, therapists must meet
legal requirements that usually include a minimum number of hours of
initial training and passing an exam. The national average number of
training hours of currently practicing therapists stands at 688 hours,
but this is likely to increase as a result of the drive to standardize
the education and practice. The National Certification Board for
Therapeutic Massage and Bodywork (NCBTMB) has been able to certify
90,000 massage therapists since 1992 through an exam required in many
States. The Federation of State Massage Therapy Boards, established in
2005, is also involved in developing national licensure examinations.
As the least developed licensed CAM profession, the massage therapy
educational community has made significant progress. It will need to
continue to work in concert with its licensing and political
organizations so that massage therapy training programs will have the
time, funding and ability to concentrate specifically on integrative
health care curricular goals. Currently, leaders of the profession are
focused on developing national educational standards that will
determine the appropriate level of skills and knowledge required to be
a licensed and certified massage therapist. In 2002, the U.S.
Department of Education recognized the Commission on Massage Therapy
Accreditation (COMTA) (2008), which has become the primary accrediting
body. At this time it has accredited approximately 100 of the estimated
1,675 massage schools and programs in the United States and Canada.
In terms of clinical training, most therapists do not experience
work in interdisciplinary settings, but this is likely to change.
Massage therapy is almost universally involved in integrative health
care clinics as part of the CAM package of therapies, and it is used in
many hospitals. For example, Lucille Packard Children's Hospital at
Stanford University offers massage therapy to patients as part of its
pain management program. Other near-term goals will be to further apply
accreditation standards to the many small proprietary training programs
that exist, and stabilize the current chaotic set of State licensing
regulations to a consistent norm.
In addition to the growing popularity and respect that massage
therapy is experiencing, it is now on the agenda for the NIH, and a
growing body of studies shows promising effects (Massage Therapy
Research Consortium, 2008). The profession has established a research
foundation (Massage Therapy Foundation, 2008), which has a database
containing over 4,800 records including both indexed and non-indexed
journal citations, and a newly formed peer-reviewed journal, the
International Journal of Therapeutic Massage and Bodywork: Research
Education and Practice. The Foundation was founded in 1990 with the
mission of bringing the benefits of massage therapy to the broadest
spectrum of society through the generation, dissemination, and
application of knowledge in the field of massage therapy.
Summary: Reform/Innovation Initiatives Within Health Professional
Education
As is evident from the reviews above, each health care discipline
faces unique challenges in making training in the integrative approach
to health care a reality. Nursing, perhaps due to its underlying
holistic philosophy, is in many ways the most advanced in this process.
In biomedicine, we see modest progress at the post-graduate level and
in undergraduate programs. Within the CAM professions, although we see
substantial movement to place more emphasis on scientific methods,
research, and EBP, it is not at all clear that enhancing the critical-
thinking skills of CAM practitioners will cause them to automatically
embrace their medical colleagues within a new integrative health care
paradigm. In fact, with regard to integrative health care per se, the
CAM professions generally have not yet developed and implemented
specific curricular objectives. Little curricular dialogue with respect
to integrative health care has taken place among a wider group of
educators in each CAM profession. Furthermore, the CAM professions'
accreditation bodies have no history of formally working with each
other.
The comparable breadth and depth of each profession's educational
infrastructure is an important issue that will need to be addressed. A
full discussion of the resource challenges facing CAM education is
beyond the scope of this paper, but it is difficult to imagine that a
wider gap could exist in the resources available to CAM education
compared to medical and nursing education. Almost all CAM training
institutions are stand-alone, not-for-profit entities that depend
almost entirely on tuition revenue to cover expenses. CAM institutions
are generally not in a position, as are many medical and nursing
institutions, to take advantage of the expertise and financial support
of publically funded universities. While a few relatively recent
significant counter examples can be cited, for all intents and
purposes, funding from grants and contracts that drive many innovative
educational and research enterprises in conventional health care
institutions simply does not exist in CAM institutions. This paucity of
financial support and all that it represents to the CAM professions is
one of the core issues that challenges the advancement of an
interdisciplinary integrative health care agenda.
There are however, two organizations that have made efforts to
bring together educators to advance integrative health/medicine
education. The Consortium of Academic Health Centers for Integrative
Medicine (CAHCIM), a group of 42 medical schools, has among its goals
to stimulate changes in medical education that facilitate the adoption
of integrative medicine curricula. The Academic Consortium for
Complementary and Alternative Health Care (ACCAHC) (2008) was formed in
2004 as a joint effort of the national educational institutions of the
fully accredited complementary and alternative health care (CAM)
disciplines. ACCAHC's mission is to advance the academic needs and
development of the evolving CAM professions, as well as the traditional
world medicine professions that are emerging in the United States; and
to foster a coherent, synergistic collaboration with academic
institutions of the conventional medical, nursing, and public and
community health professions. ACCAHC includes the following licensed
CAM professions: Acupuncture and Oriental Medicine (also called TCM),
chiropractic medicine, direct entry midwifery, massage therapy and
naturopathic medicine.
In summary, educational reforms in the major health professions,
specifically with respect to integrative health care goals, vary
considerably depending on the overall current state of development of
each profession. Common to all the CAM professions, however, is that
they all suffer from lack of access to adequate financial and human
resources that could be used to meet the educational goals of a well-
integrated health care system. Nevertheless, progress is certainly
possible and indeed, is beginning to be visible. Overtures by medical
institutions seeking to initiate educational efforts to promote
integrative health care will generally be seen as consistent and
desirable with CAM educational goals as well, especially in
interdisciplinary care.
ATTITUDES OF HEALTH PROFESSIONALS
As consumer use of CAM has increased and evidence has accumulated
demonstrating safety and efficacy of CAM approaches, attitudes of
conventional health care providers towards CAM have become more
favorable. Very few studies have focused on attitudes of CAM providers
and no studies were found that focused specifically on attitudes of any
professional group towards integrative health care, as distinct from
CAM.
The largest numbers of studies have examined physician attitudes
and practice patterns related to CAM. In a regional survey conducted by
Berman et al. (1995), over 90 percent of respondents expressed the view
that CAM approaches, such as diet and exercise, biofeedback and
behavioral medicine, are legitimate medical practices. Over 70 percent
of respondents indicated that they were interested in more training in
areas including hypnotherapy, massage therapy, acupressure, herbal
medicine, and prayer. In a subsequent national survey, Berman et al.
(1998) reported that physicians in practice more than 22 years had the
least positive attitudes towards CAM and that attitudes and training
were the best predictors of use in professional practice. In a survey
of primary care and medical subspecialties practitioners, Crock et al.
(1999) found that overall, physicians demonstrated an open attitude
toward CAM, but had low rates of referral for CAM therapies. In a study
of physicians in an academic health center, Wahner-Roedler et al.
(2006) reported that the majority of physicians agreed that some CAM
therapies hold promise for the treatment of symptoms or diseases but
most of them were not comfortable in counseling their patients about
CAM treatments. In a study of osteopathic physicians, Kurtz et al.
(2003) reported that family physicians and internists were more likely
than pediatricians to talk to their patients about CAM or refer their
patients for CAM. Physicians 35 years of age and younger were more
likely than those over 60 to use CAM for themselves or their families.
In a study of critical care nurses, Tracy et al. (2003) found that
despite barriers including lack of knowledge, time and training, 88
percent of respondents were open or eager to use complementary
therapies in their practice. In a study of faculty and students in an
academic health center, Kreitzer et al. (2002) found that 90 percent of
medical and nursing school faculty and students believed that clinical
care should integrate conventional care and CAM therapies and that
health professionals should be able to advise their patients about
commonly used CAM methods. In a recently published literature review
that summarized 21 surveys of physicians, nurses, public health
professionals, dietitians, social workers, medical/nursing faculty and
pharmacists, Sewitch et al. (2008) concluded that overall, physicians
demonstrated more negative attitudes towards CAM compared to other
health care professionals. Positive attitudes toward CAM did not
correlate with CAM referral or prescription patterns, and health care
professionals of all disciplines wanted more information about CAM.
Very few studies have focused on the attitudes of CAM practitioners
towards working with biomedical practitioners. In a qualitative study
of CAM practitioners, Barrett et al. (2004) reported that CAM providers
stressed the holistic, empowering, and person-centered nature of CAM
and that they describe themselves as healers. While calling for the
greater integration of conventional and complementary health care,
these authors identified that attitudes and beliefs were often larger
impediments to integration than were economic or scientific
considerations. A study of students' perceptions of interprofessional
relationships in eight health professional programs including
chiropractic using the Interdisciplinary Education Perception Scale
revealed substantial differences among the students in perceptions of
competence/autonomy, perceived need for cooperation, perception of
actual cooperation, and understanding others' value (Hawk et al.,
2002). Data from one study revealed that chiropractors do not identify
their profession as falling within the domain of CAM. Redwood et al.
(2008) surveyed chiropractic faculty and practitioners and reported
that 69 percent do not believe that chiropractic should be categorized
as CAM. Twenty-seven percent (27 percent) thought that chiropractic
should be classified as integrative medicine.
Kaptchuk et al. (2005) have advocated the concept of ``pluralism''
as opposed to ``integration'' as a philosophy or attitude to ground the
ongoing discussion between biomedical and CAM practitioners:
``Integration . . . ignores unbridgeable epistemological
beliefs and practices between mainstream and alternative
medicine. Pluralism, which has been relatively ignored, calls
for cooperation between the different medical systems rather
than their integration. By recognizing the value of freedom of
choice in medical options, pluralism is compatible with the
principle of patient autonomy . . . Pluralism encourages
cooperation, research, and open communication and respect
between practitioners despite the possible existence of honest
disagreement, and preserves the integrity of each of the
treatment systems involved.''
Pluralism may ultimately prove the most reasonable approach to
bridge the gaps in paradigm and tradition between the health care
professions while at the same time promoting discussion and dialogue.
EDUCATIONAL STRATEGIES FOR EFFECTING CHANGE
Identification of Core Competencies
The IOM report, Health Professions Education: A Bridge to Quality
(IOM, 2003) has already been mentioned as a highly influential document
urging substantial changes that are highly consistent with the goals
and hopes of integrative health care. The IOM committee spent
considerable effort to make recommendations to introduce core
competencies for an outcome-based education system that better prepares
practitioners to meet the needs of patients and the requirements of a
changing health care system. The competencies are: (1) provide patient-
centered care; (2) work on interdisciplinary teams; (3) employ
evidence-based practice; (4) apply quality improvement; and (5) utilize
informatics. The report emphasizes that the core competencies are meant
to be shared across the health professions and that careful
consideration should be paid to the cultural changes necessary to
support their inclusion. Notably, however, the document is silent on
the issue of integrative health care.
Kligler, et al. (2004), representing the Educational Working group
of the CAHCIM, identified 30 competencies in integrative medicine in
the four domains of values, knowledge, attitudes, and skills. The
authors also discussed challenges to educators and provided some
specific successful examples of implementation and evaluation. The
overarching goal was to develop ``a coherent, generally agreed-upon
framework that articulates the core knowledge to be mastered by medical
students.'' The competencies in the report were derived after a 2-year
process of dialogue on the content, process and scope of integrative
medicine education.
The authors expanded the standard knowledge/attitudes/skills format
in order to emphasize that humanistic values and philosophical
perspectives should be the foundation for an integrative approach to
health care. They emphasized the value of experiential learning, self-
care and reflection, and the need for faculty development in this area.
They also acknowledged the presence of substantial challenges
concerning how competencies could be implemented and properly evaluated
in individual institutional settings.
The impact and implications of the CAHCIM document (Kligler et al.
2004) were almost immediately recognized by educational leaders of CAM
institutions represented by the ACCHAC. It stimulated a vigorous
discussion that ultimately led to a formal response published in the
Journal of Alternative and Complementary Medicine in 2007 (Benjamin et
al. 2007). The ACCHAC took issue with a number of points in the CAHCIM
paper, these concerns were clarified through a Delphi process with
ACCHAC members. Five key areas of concern emerged: (1) the definition
of integrative medicine as presented, (2) lack of clarity regarding the
goals of the proposed integrative medicine curriculum, (3) lack of
recognition of the breadth of whole systems of health care, (4)
omission of competencies related to collaboration between medical and
CAM professionals in patient care, and (5) omission of potential areas
of partnership in integrative health care education. At root were
familiar concerns of the CAM professions that they were being
relatively ignored while their approaches, methods, and values were
being adopted by medical educators. A clear desire was expressed by the
CAM professions to be better recognized and included as equal partners
in the evolution of integrative health care education. The ensuing
dialog between CAHCIM and ACCHAC was fruitful; in 2005, CAHCIM revised
its definition of integrative medicine to more clearly indicate that
collaboration with ``. . . all appropriate therapeutic approaches,
healthcare professionals and disciplines to achieve optimal health and
healing,'' should be a hallmark of integrative health care (Benjamin et
al. 2007).
A related effort was spearheaded about the same time by the
National Education Dialog to Advance Integrated Health Care (NED)
(Weeks et al. 2005), a multidisciplinary collaboration of CAM and
conventional medical educators and policymakers that culminated in a
meeting at Georgetown University in 2005. The vision of the NED was
stated to be a ``. . . healthcare system that is multidisciplinary and
enhances competence, mutual respect, and collaboration across all CAM
and conventional healthcare disciplines.'' Among nine recommendations
for action, at least five involved education including one on inter-
institutional relationships and one on developing competencies on
shared values, skills and attitudes. Both of these had implications for
refining workable integrative health care competencies, but the process
fell short of operationally defining the competencies in any detailed
fashion. Nevertheless, this cross-disciplinary meeting identified many
of the challenges and opportunities for shared educational efforts.
Subsequent dialogue by a subset of NED participants identified, as
have others, that with respect to the goal of interdisciplinary
collaboration, the set of knowledge, skills, and values identified for
Practitioner to Practitioner Relationships in Relation-Centered Care
developed by the Pew-Fetzer Task Force on Advancing Psychosocial Health
Education could provide an excellent foundation (Tresolini, 1994).
While the Pew-Fetzer Task Force was not focused on integrative health
care per se, it listed 24 learning goals organized into four topic
areas: self-awareness, traditions of knowledge in health professions,
building teams and communities, and working dynamics of teams and
communities. While also leaving something to be desired in the way of
specific measurable competencies, there is a notable consistency of the
Pew themes with efforts to define competencies for integrative
medicine.
A different and instructive effort from the field of allied health
attempted to ``harmonize'' core competencies to develop a framework for
interprofessional education for medicine, nursing, occupational
therapy, and physical therapy in Canada (Verma et al. 2006). While also
not focused on integrative health care, this effort identified
challenges to collaboration across disciplines within the umbrella of
conventional medicine which apply even more clearly to the gulf that
has separated the conventional and CAM professions. By reviewing key
competency documents from the four professions, they were able to
demonstrate substantial convergence in six domains or roles, that of: a
professional (including as a health advocate), an expert, a scholar, a
manager, a communicator, and a collaborator. The authors felt that the
perceived competency silos of each profession were, in fact, more
perceptions than real, and that with some effort, shared competencies
can be identified and implemented. The emerging importance of team-
based skills and interdisciplinary education to integrative health
care, and the attendant challenges are discussed in further detail
below.
Recently, Kreitzer (Kreitzer et al. 2008) surveyed the principal
investigators of the aforementioned NCCAM awarded R-25 grants to 15
medical and nursing programs in order to obtain recommendations on the
core competencies in CAM that had evolved during the course of their
projects for conventionally trained students, physicians and nurses.
Responses varied substantially depending on the original aims and the
context in which the grantees were able to execute ideas. Nevertheless,
five thematic domains emerged. These were described as: (1) awareness
of CAM therapies and practices, (2) the evidence base underlying CAM
therapies, (3) CAM skill development (primarily focused on cultural
competence skills to enhance patient communication about CAM use, but
relatively little on specific CAM treatment skills), (4) self-awareness
and self-care (particularly mind-body approaches to alleviating
stress), and (5) CAM models and systems. While perhaps partially
explained by the overlap between the institutions receiving R-25 grants
and the institutional members of CAHCIM, it was noted that the
``grassroots'' results obtained by 15 programs over time demonstrated
considerable consistency with those developed by the more focused
CAHCIM consensus process. The details and differences reflected in the
NCCAM grant-driven domains probably reflect practical experience and
more realistic expectations, but the degree of consistency with the
loftier goals set by the CAHCIM document is encouraging because it
demonstrates that curricular changes are possible.
At this juncture, the dialogue continues, but now with a growing
base of experience and an acknowledged set of key publications from
authoritative sources in both the conventional and CAM worlds. There is
some controversy as to what, if any, level of skill should be expected
of physicians in recommending specific integrative approaches to
patients--and as such if the suggested CAHCIM competencies demand more
than may be practical as expected competencies for all physicians.
There is however, general agreement that the recent IOM recommendation
that physicians be ``competent to advise'' patients about CAM
represents a basic competency that can be expected of all medical
school graduates. The challenge has been to clarify and describe what
comprises this competency--i.e., what level of knowledge and/or
experience of CAM should be required--and how to measure it. The most
common approach has been to teach and then test for this as a
``communication'' competency i.e., expecting that all physicians will
incorporate inquiry on patients' use of CAM into their history taking
in a nonjudgmental manner. This competency shares much with
competencies now expected in patient-centered communication and
multicultural sensitivity. Several schools are now using either
observed standardized clinical encounters or standardized patient
scenarios to evaluate students and residents for their competency in
this particular skill (Kligler et al. 2007).
There is a similar and equally important controversy surrounding
what level of competency in primary care (i.e., diagnosing and either
treating or properly referring common presenting problems) should be
expected of CAM professionals. Some of the professions--naturopathy,
chiropractic and traditional Chinese medicine most notably--already
define such competencies for their profession, but others do not. If
the health care system of the future is going to more closely
interweave the health professions, the role and responsibility of the
``first contact'' with a patient needs to be defined much more
explicitly and in a fashion which will lead to more trust,
collaboration, and referral across and between specialties. This inter-
profession discussion of what comprises ``competency'' in primary care
will be difficult because it will also involve many questions of
``turf,'' reimbursement, and power, but we cannot hope to move to the
next level of integrative care without finding a way to promote such a
dialogue as part of the discussion of shared competencies.
Once we reach a wider consensus about the shared competencies that
will support the infrastructure for truly integrated and integrative
health care, we will face the challenge of measuring whether these
competencies are being taught effectively. This is a challenge facing
all the health professions individually as well as we move from
evaluating only the cognitive skill domain to trying to define
measurable behaviors that will actually impact patient care. Here
again, nursing has much to teach the other professions, having focused
for a number of years already on defining and evaluating behavioral
competencies.
Interdisciplinary Education
The IOM report on Health Professions Education provides the best
template currently available for how to move forward training in
integrative health care in its emphasis on multidisciplinary/team-based
education. The report describes a wonderful vignette of an
interdisciplinary learning team--comprised of medical, pharmacy and
nursing students--collaborating on the care of a complex inpatient
(IOM, 2003). Each profession addresses the area of care most relevant
to its role, and information is shared continuously and freely. An
environment of respect pervades the team communications, which
ultimately spills over to the approach to the care of the patient. The
model falls short only in its failure to include students of the other
healing arts--acupuncture, chiropractic, massage therapy, for example--
in its vision.
Although there are some examples of interdisciplinary strategies to
integrative health care education, to date many medical schools have
focused on either M.D. faculty teaching about CAM, or faculty from
local CAM schools doing this teaching as guest faculty. There is some
evidence that this approach--simply incorporating the ``CAM'' content
into the conventional curriculum, or engineering occasional appearances
as teachers by CAM practitioners--may not be enough to engender
widespsread culture change and true integration of the different
healing paradigms. A report from one of the NCCAM-funded R-25
institutions at Oregon Health Sciences University (OHSU) found that
having CAM practitioners teaching about CAM has not had a significant
impact on OHSU's culture. These authors reported that ``attitudes held
by faculty at OHSU are largely unchanged by these research,
educational, and clinical initiatives, as serial qualitative interviews
have demonstrated (Nedrow et al. 2007).''
Two examples of pilot programs bringing students from conventional
medicine and CAM disciplines together early in training are based on
the idea that sharing common experiences early in training will break
down barriers to effective collaboration and communication in a way no
amount of teaching ``about'' CAM or even contact with CAM school
faculty can do. First-year medical students at the University of
Minnesota have an immersion experience in TCM at Northwestern Health
Sciences University as part of a first-year required course. In
addition to interacting with TCM students and faculty and learning
about its theoretical basis, students observe and experience various
aspects of TCM (NED 2005). Another such collaborative program occurs
between Georgetown School of Medicine and the Potomac Manual Therapies
Institute: PMTI students visit the Georgetown anatomy lab where medical
students lead a 90-minute cadaver tour. Medical students then visit
PMTI and massage therapy students offer the Georgetown students an
experience of massage, with appropriate education on application and
techniques. Between 2003 and 2006, 120 PMTI students (50 percent of the
student body) and 80 Georgetown students (25 percent) had participated
in the program (Kreitzer and Sierpina, 2006). According to the program
faculty, this effort demonstrates that ``personal encounters, working
side by side and learning about each other's discipline, result in
mutual respect, which may ultimately contribute to the creation of an
integrated health care system.''
Although a body of research literature is emerging studying the
outcomes of interprofessional educational (IPE) efforts, some degree of
controversy remains as to whether this approach can actually be said to
change the behaviors of the professionals involved. Hammick et al.
(2007) reviewed 21 studies of IPE programs and concluded that these
interventions are generally well-received and facilitate the
development of skills in working collaboratively across disciplines,
but that it is more difficult to demonstrate a clear impact on the
behavior of the service delivery team. In a Cochrane review, Reeves et
al. (2008) evaluated six studies of IPE interventions which met their
inclusion criteria, and found that although most studies reported
positive outcomes, it was not possible to draw real conclusions about
the key elements of each intervention or their overall effectiveness.
These authors and others call for more rigorous study of IPE
interventions, incorporating an evaluation process to document the
impact on the processes of care delivery and on patient-centered
outcomes. Whatever efforts move forward to promote interdisciplinary
training in integrative health care should include a research component
examining the impact of these initiatives.
Interdisciplinary Graduate Programs in CAM or Integrative Health Care
Several types of interdisciplinary graduate programs have emerged
that focus on CAM or integrative health care. Some are offered through
interdisciplinary centers or programs within universities and others
are offered through collegiate programs, such as schools of medicine.
In 1999, the University of Minnesota approved an
interdisciplinary graduate minor in complementary therapies and healing
practices and subsequently began offering a graduate certificate
program in CAM with an optional track in health coaching. The minor
enables students pursuing masters or PhD degrees to enhance their
degree program by focusing on CAM. The program attracts clinicians and
researchers who aspire to practice or conduct research in integrative
health.
Georgetown University introduced a CAM-oriented, science-
based master of science in physiology in 2003. The program is designed
for students interested in careers in research, industry, regulatory
affairs, CAM practice, or the practice of medicine. In 2005, Georgetown
School of Medicine launched a 5-year M.D./MS track that enables
students to complete the 4-year medical school curriculum and the CAM
MS degree.
In 2003, Tufts University School of Medicine and the New
England School of Acupuncture (NESA) launched a unique collaborative
program. While completing a master's degree at NESA, students can
simultaneously enroll in a multidisciplinary pain management program at
Tufts, thereby also earning a master's degree from Tufts.
The University of Medicine and Dentistry of New Jersey
School of Health Related Professions recently launched an online 30-
credit MS degree in health sciences with a new track in integrative
health and wellness. The track focuses on preparing licensed and
certified health professionals to expand their competencies in CAM
practices.
Each of these programs represent a unique path that offers students
options to expand their expertise in CAM or integrative health care
beyond information that may be obtained within their basic health
professional education program.
Interdisciplinary Undergraduate Programs in Wellness or Integrative
Health
Several types of interdisciplinary undergraduate programs have
emerged that focus on wellness, CAM or integrative health. As noted by
Burke et al. (2004), these programs are helping to build an education
infrastructure at the baccalaureate level and may consist of a minor,
major or certificate program. For example, San Francisco State
University (SFSU) has been offering a series of holistic health courses
since 1976. The Institute for Holistic Studies at SFSU, under the
department of health education, offers a minor in holistic studies.
Students enrolled in the minor take a set of courses that introduce the
students to holistic health concepts. These courses are followed by
advanced CAM courses in areas such as biofeedback and Chinese herbs.
Similar minors are offered at Metropolitan State College of Denver and
Georgian Court College in New Jersey. Northern New Mexico College
offers a bachelor of science degree in Integrative Health Sciences
(IHS). The IHS program accepts both new students and students with
health backgrounds who want to gain knowledge and skill in integrative
health. A wide range of courses is offered including aromatherapy,
nutrition, energy healing and acupressure. These programs are
attracting students who are planning to become health professionals and
who wish to supplement their training with courses that focus on
holistic health early on as well as students who enroll for personal
development.
Innovative Teaching Methodologies/Transformational Learning
Along with a need for frequent and extensive contact with other
health care disciplines throughout professional training, there is
growing consensus among many health care educators that teaching about
CAM--whether done by M.D.s or by CAM faculty--although necessary as
part of the integration process, is not sufficient. Because a true
integration of CAM into the health care system will require medical
students and physicians to expand their perspective on what constitutes
``healing,'' reflection-based curriculum must be part of this process.
Just as health care practitioners cannot learn to practice patient-
centered medicine or culturally competent health care without some
capacity for reflection on the impact of their own behavior and
attitudes on the patient's experience, without an experiential/
reflective component the integrative approach cannot be taught
effectively: ``For example, a lecture on acupuncture is unlikely to
capture the sensate experience of having an acupuncture needle placed
or the deep relaxation which may be experienced through a practice such
as tai chi. Similarly, describing the physiology of the relaxation
response may be less effective than having students experience it
directly through a meditation exercise. Inclusion of traditional
systems of medicine and other complementary approaches requires both a
synthesis of additional facts and a need for experience-based
understanding to facilitate real clinical awareness (Kligler et al.
2004).''
Separate and apart from the world of CAM and integrative health
care, medicine as a discipline is wrestling with how to incorporate
reflection, mindfulness, and self-awareness into medical training
(Dobie, 2007). This effort is taking shape in the wide array of
curricula in professionalism which have been developed at schools
around the country in response to an LCME mandate for teaching in this
area. Much of the genesis of this movement relates to the IOM statement
in 2001 identifying the ``continuous healing relationship'' as the
foundation for improving all patient care (IOM, 2001). The consensus
emerging regarding the importance of experiential/reflective teaching
strategies in this area is demonstrated by the fact that 14 of the 15
NCCAM R-25 grantees rated self-awareness and reflection activities as
highly or very highly-valued components of their curriculum development
plan (Elder et al. 2007).
The best example of a widely accepted reflection-based in medical
education is the Healer's Art Program. This teaching program was
developed at the University of California, San Francisco, and is now
offered in over 50 medical schools as an elective. This 4-6 session
program, taught in small groups, utilizes a variety of reflective
exercises designed to help students develop and maintain an
understanding of the ``human dimension of health care'' and on
understanding and maintaining a clear commitment to the meaning of
their work (Remen and Rabow, 2005). In one session typical of this
course, students work to write their own Hippocratic oath to describe
how they hope to realize the values and attitudes which brought them
into medicine as a profession.
IMPACT OF A NEW HEALTH CARE MODEL ON HEALTH PROFESSIONS EDUCATION
Changes in the health care system, such as a new care model, could
both accelerate and reinforce changes being made in health professions
education to advance integrative health. Currently, there are very few
examples of integrative health or integrative medicine being practiced
in a comprehensive and systematic manner in primary care, acute care,
long-term care, or public health settings. This makes it challenging to
educate students and it creates dissonance in graduates who, if they
are educated in integrative health, may become quickly discouraged and
disillusioned if they are unable to practice what they have learned.
For integrative health care to advance the health of the public, there
needs to be alignment in education, workforce development and
deployment and practice settings. Primary care will be used to
illustrate this point.
The American College of Physicians recently warned that ``primary
care, the backbone of the Nation's health care system, is at grave risk
of collapse'' (ACP, 2006) There is a confluence of factors contributing
to challenges currently facing the U.S. health care system. An
estimated 47 million people do not have insurance, thus limiting their
access to care. With the aging of the population, there is a dramatic
increase in chronic illness. Factors contributing to chronic illness
include many lifestyle patterns including poor diet, lack of exercise,
smoking and chronic stress. As noted by Bodenheimer and Laing (2007),
the 15-minute office visit does not allow the provider to provide
acute, chronic and preventive care, build relationships with patients
and manage multiple, complex diagnoses. The system as structured is
expensive and achieves less than desirable outcomes. Solutions often
proposed include generating more primary care physicians and reforming
the payment system that may undervalue office visits and overvalue
technological and procedural services. At best, these strategies would
enable us to produce more of the less than satisfactory outcomes that
are presently being generated.
Fundamental reform of the system requires that we address the
following questions:
What are the health care needs of the public?
Who are the health care providers best prepared to meet
those needs?
How can the strengths and assets of the workforce be
leveraged to improve patient outcomes and reduce costs?
What models of care will enable us to move from the
current health care system that is sporadic, reactive, disease-oriented
and physician-centric to one that fosters an emphasis on health,
wellness, early intervention for disease, patient empowerment and a
focus on the full range of physical, mental and social support needed
to improve health and minimize the burden of disease?
To achieve better outcomes and to reduce costs, it is proposed here
that the health care system focus on integrative health care throughout
the continuum of care and to more strategically use the full complement
of health professionals within the workforce. Primary care includes
health promotion, disease prevention and the management of acute and
chronic illness. A first line of care could include nurse practitioners
and nurse midwives who can manage an estimated 80 percent of primary
care. Primary care physicians could complement and support this care
with specific emphasis on management of patients with more complex
chronic illness. Ideally, within the primary care system, patients
could also access chiropractors, TCM providers, naturopathic
physicians, massage therapists, and other CAM professionals skilled in
health promotion and disease prevention as well as management of
chronic disease. This team or cadre of health professionals along with
health coaches, are optimally positioned and prepared to help people
examine lifestyle patterns and choices. Typically, medical doctors, who
the system currently relies heavily on for primary care, receive
minimal training in nutrition and health promotion.
The U.S. health care system is unparalleled in the use of
technology, the management of trauma and the diagnosis and treatment of
patients with complex acute and chronic illnesses. Advances in areas
such as surgery, oncology, transplantation, infectious disease,
neonatal care, intensive care, and high-risk pregnancy are both life
saving and life enhancing. It is well documented that M.D. specialists
who perform high volumes of diagnostic and surgical procedures attain
better outcomes than colleagues who perform procedures with less
frequency. This both justifies and re-
inforces the need for specialty training of physicians from a workforce
perspective.
In an effort to improve primary care, several innovative models
have recently been proposed that could be significantly enhanced by
including a focus on integrative health care.
Primary Care Innovation
Over the past 5 years, as the need to change the primary care
system has become more apparent and urgent, ideas for innovation have
emerged. Two models will be highlighted: the medical or health care
home concept and the teamlet model of primary care. These models will
be examined from the perspective of both the health care needs of the
population and the workforce strengths and capacities.
Medical home concept: The American Academy of Pediatrics (AAP)
first introduced this concept in a 1992 policy statement (AAP, 1992)
advocating that a pediatrician or other primary care physician should
be identified as a regular source of primary care for the patient. In a
2002 policy statement, the AAP (2002) expanded the definition of
medical home to include the following operational characteristics:
accessible, continuous, comprehensive, family-centered, coordinated,
compassionate, and culturally effective care.
More recently, the American College of Physicians (ACP), American
Academy of Pediatrics, the American Osteopathic Association and the
American Academy of Family Physicians (AAFP) have endorsed this concept
and have issued a statement on joint principles of the patient-centered
medical home (AAMC, 2008). The concept of the medical home as defined
in this document is that every person should have access to a primary
care base where they have access to a person who serves as a trusted
advisor and provider. This provider is supported by a coordinated team,
with whom the patient has a continuous relationship. The medical home
promotes prevention; provides care for most problems and serves as the
point of first-contact for that care; coordinates care with other
providers and community resources when necessary; integrates care
across the health system; and provides care and health education in a
culturally competent manner. It is proposed that payment for the
medical home model should appropriately recognize and reward health
care providers for their contributions to prevention, patient care, and
care coordination. This model is often referred to as a patient-
centered and physician-guided model of care.
The focus on accessibility, health promotion, disease prevention,
chronic disease management, and coordination of care attains much of
what is described above as being desirable in a reformed health care
system. The model falls short in two respects: it neglects to reflect
the inclusion of integrative approaches to healing including the use of
licensed CAM providers and it presumes that the M.D. is the only
capable and prepared provider around to organize the medical home
concept. A modified approach might describe this as a ``health home''--
rather than a ``medical home''--that leverages the capacities of nurse
practitioners, chiropractors, and naturopathic physicians, among
others, to provide primary care as well as first point of entry care.
The underlying operating assumption would be to use less invasive and
expensive methods first, including the use of CAM. Some consumers, for
example, may opt to access a traditional Chinese medicine provider as
the first point of entry. M.D. specialists would be used to access the
unique and indispensable care that only they can provide. Health
coaches could also be effectively used in this model.
Teamlet model of primary care: Bodenheimer et al. (2007) have
described an innovation called the teamlet model. The presumption is
that all primary care practices have a team. The team varies
significantly with the size and type of the practice but has, as a
constant feature, the clinician-health coach dyad. Goals of the teamlet
model include improving the patient experience and enhancing patients'
self-management skills, improving preventive and chronic care,
improving the work life of primary care clinicians, ensuring that all
practice personnel are working to their fullest potential, and cutting
health care costs by reducing unnecessary hospitalizations and
emergency visits through intensive management of high-risk and high-
utilizing patients by using health coaches. While some practices
operate with the ratio of one clinician to two health coaches, others
have successfully used a ratio of five coaches per two clinicians.
Under this model, patients generally spend more time with the health
coach than the primary care clinician. Bodenheimer et al. are not
prescriptive as to the background and training of the primary care
clinician. Presumably, it could be any of the health professions
described in this paper who are trained to provide primary care. While
this model does not describe integrative health care per se or the use
of CAM, it seems reasonable that the model could be modified to include
this expanded perspective.
Regarding the exploration of the role of new models of integrative
care in our future health care system, a small but potentially
important step was taken recently in the convening of a ``scoping''
meeting jointly organized by HRSA, the Samueli Institute, and the
Institute for Alternative Futures to explore the role of integrative
health care in reducing health disparities for underserved populations
(Fritts et al. 2009). A planning process is now underway to study and
disseminate information more widely on the potential role of increasing
access to an integrative approach as one solution to some of our
current problems with access to high quality care for chronic illness
in the United States.
SUMMARY
Over the past decade, many authoritative sources, including the IOM
and the Association of Academic Health Centers, have repeatedly
identified deficiencies in the training of the U.S.-health care
workforce that if addressed could lead to a better health care system.
At the same time, other authoritative sources have chronicled the
growing interest in what is becoming known as integrative health care.
By virtue of its overarching humanistic philosophy and broad
biopsychosocial perspective aligned with evidence-informed clinical
decisionmaking, integrative health care could have the power to
transform the training of all health care professionals to be able to
deliver a safer, more effective and more coordinated form of care to
the public. Admittedly, this is a bold statement that will require bold
steps to bring into reality.
This paper has attempted to set the stage for future action by
reviewing recommendations for curricular reform that have emerged from
the IOM Committee on Health Professions Education, the IOM Committee on
Use of Complementary and Alternative Medicine, the White House
Commission on Complementary and Alternative Medicine and the National
Education Dialogue. Each of these efforts has involved dedicated
educational experts committed to high ideals. We subsequently
summarized the initial seed efforts by NIH NCCAM to stimulate
curricular reform in both conventional and CAM institutions. Many
lessons can be derived from these collective efforts to change
institutional and professional cultures that have proven resistant to
change on many levels in both the CAM and conventional worlds. A more
concerted and coordinated set of initiatives will need to be developed
to move the training of all health care professionals to a new level.
Our review of two conventional (medicine and nursing) and four
licensed CAM professions (chiropractic, naturopathy, TCM and massage
therapy) highlight the opportunities that exist for a more coordinated
health care workforce, but also the challenges that exist to bringing
disparate professions together. We summarized the educational
preparation and workforce structure of CAM and biomedical professions
and their efforts to make curricular changes that advance integrative
health care. It is abundantly clear that the glaring differences in
resources, needs, and motivations of conventional health care training
institutions compared to CAM institutions will require sensitivity,
significant resources and extraordinary collaborative leadership.
While significant challenges exist, we also determined that the
attitudes of health professionals toward integrative health care and
CAM are undergoing significant shifts. Medical and CAM leaders have
officially organized themselves to begin a dialogue to identify
innovative strategies that could impact each health profession's
education. These have resulted in the development of specific
integrative health care competencies and interdisciplinary education
initiatives at the undergraduate and graduate level that show great
promise. In concordance with efforts under the umbrella of integrative
health care, medical leaders have separately identified a number of
primary care models that have the potential not only of transforming
the way most health care is delivered, but also how interdisciplinary
care is taught and modeled in all health care professions' training.
These models have great potential for bringing together the new
thinking on both primary care and integrative health care.
Finally, in the next section we offer recommendations that will
advance integrative health care and enable the movement from the
current U.S.-health care system that is sporadic, reactive, disease-
oriented, and physician-centric to one that fosters an emphasis on
health, wellness, early intervention for disease, patient empowerment,
and a focus on the full range of physical, mental, and social support
needed to improve health and minimize the burden of disease.
RECOMMENDATIONS
The following recommendations address how the health of the public
may be served by incorporating an integrative health perspective into
health professions education and workforce planning, deployment and
utilization.
1. Convene a high level, interdisciplinary group, supported by
HRSA, to be charged with developing core competencies in integrative
care for all health professions students. This group should include
representatives of the major accrediting bodies for the licensed health
professions as well as leading educators from each profession. This
will be a complex, multi-year process and will require significant
administrative and funding support.
2. Bold innovation and reform is needed in health professions
education that will expand the focus of education from the treatment
and management of disease to one that includes a focus and emphasis on
wellness. Regulatory bodies governing education in the various health
disciplines should be charged to mandate the inclusion of integrative
health in basic, advanced and post-graduate training. At a minimum,
this should include content on:
patient-centered and whole person care;
personal responsibility for health and wellness;
lifestyle choices, behaviors and outcomes including but
not limited to diet, exercise, and stress reduction;
health promotion and disease prevention; and
knowledge, principles, practices and processes that
facilitate the integration of conventional biomedical care with CAM.
3. Academic programs preparing health professions should be urged
by the IOM and their regulatory bodies to create within their
institutions a culture of wellness that includes a focus on self-care
and reflection of one's own health and wellness behaviors.
4. At the Federal and State level, legislation and regulation
should be implemented that will create incentives and reimbursement
structures for conventional and licensed CAM health professions that
accelerate reform and innovation in the health care system and that
will achieve the following outcomes:
Emphasis on health and wellness,
Early detection and intervention for disease,
Personal responsibility and patient empowerment,
Access to integrative health options throughout the
continuum of care, and
Team-based care that maximizes utilization of conventional
and CAM practitioners.
From an education perspective, it is critical to have clinical
sites that enable students to obtain experience in integrative health
and medicine and that reinforces learning acquired in the classroom.
5. Changes in legislation and regulation should be enacted at the
State level that will enable health professionals including CAM
providers and advance practice nurses to practice to the top of their
license. Barriers should be removed that prevent health professionals
from providing care and treatment that they are trained to safely
provide.
It is anticipated that these changes will impact recruitment into
health professions education and training programs.
6. The Department of Health and Human Services and other Federal
and State agencies responsible for workforce planning should be
required to develop a national strategic vision for workforce planning
that is based on new models of care and that encompasses conventional
and licensed CAM providers.
References
Academic Consortium for Complementary and Alternative Health Care. IHPC
Promotes Education for Integration. http://ihpc.info/education/
education.shtml (accessed November 15, 2008).
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Senator Mikulski. Mr. Duggan.
STATEMENT OF ROBERT M. DUGGAN, M.A., M.Ac., PRESIDENT, TAI
SOPHIA INSTITUTE, LAUREL, MD
Mr. Duggan. Thank you, Senator. Thank you for giving me
this opportunity to speak to you and the committee.
I speak representing the faculty, the staff, the board, the
patients of the Tai Sophia Institute in Laurel, MD, an
accredited graduate school with more than 400 full-time
students studying the healing arts.
In many ways, we are representative of the industry Wayne
mentioned, a school grown outside of the existing healthcare
system and existing healthcare framework. We have more than
1,200 graduates across the country, and they are, indeed, the
beginning of a national wellness corps, a corps of teachers of
wellness. I have submitted more detailed written comments.
I speak as someone who has practiced the art of healing for
more than 41 years, and I have learned a great deal from my
patients about the importance of patient-centered and
relationship-centered care.
Tai Sophia is an anchoring academic institution for an
American wellness system. The training ground for those who can
teach and motivate others, including our existing healthcare
providers, as several previous speakers have mentioned--
teaching them and motivating them to care for themselves, to
live wisely, to reduce their stress so that we can re-engage
the entire population in self-care.
As an educator, I have a problem that I hope Congress could
help with. The financial incentives for all of our graduates
and students are the same as those for all healthcare
professionals--to work with a disease, to prove in order to be
reimbursed that their particular methodology of dealing with
the disease is better than someone else's methodology for
dealing with that disease.
They are reimbursed essentially for making people dependent
on them with repeated treatments and visits for dealing with
that disease rather than being reimbursed for motivating,
teaching, and empowering people with the best ways to stay well
using community and family resources. All the financial
incentives for our students and graduates reward fixing the
disease, not maximizing independent living.
When we first opened the institute in 1975, a wonderful
Howard County physician, the founder of one of the Nation's
first HMOs in Columbia, MD, said to us, ``If you know something
about treating a tummy pain before it becomes an ulcer, go for
it. I am only trained to treat it when it has become a
pathology.''
Those words have stayed with me and our community through
the years. All of our Nation's medical and healthcare
incentives are geared toward the treatment of disease, not the
promotion of wellness.
Given the importance of shifting those incentives, I
recommend, as several colleagues have already done, first, the
creation of a national office, perhaps in the White House,
charged with motivating habits of wellness in every aspect of
American life--in our schools, in our agriculture, in our
military, in our environmental affairs, as well as in the
healthcare system.
Second, that we fund, perhaps using funds from the stimulus
package, demonstration initiatives in many local communities,
such as you saw the other day with Peter Beilenson in Howard
County, demonstrations designed to reduce medical expenditures
when healthy lifestyle habits are reinforced at a community
level.
I think of the example with first grade children. Do we
want to give them Ritalin, or do we want to teach them yoga and
tai chi and engage them in exercise? It is the kind of example
that immediately comes to mind.
Third, that we have a program to train all current
healthcare providers to understand their own bodies. Many
healthcare workers are on burnout and exhaustion, and they need
to maintain their own wellness. As they do that, I trust it
will help all of their patients.
Fourth, create national wellness educational programs that
enable and empower individuals and families to learn to be
motivated to be their own primary care providers.
And finally, to fund the development of a series of
wellness universities across the United States, such as Tai
Sophia, to train a national corps of wellness educators for our
schools and our communities.
Thank you for giving me this opportunity.
[The prepared statement of Mr. Duggan follows:]
Prepared Statement of Robert Duggan, M.A., M.Ac.
Albert Einstein: ``The significant problems that we have cannot be
solved at the same level of thinking we were at when we created them.''
The American Wellness Systems--An Alternative Way of Thinking
The usual conversation about the American healthcare system
revolves around what is called ``the iron triangle of cost-quality-
access.'' In reality, a change in any one of these aspects will affect
all the others. We suggest that the ``iron triangle'' presents a false
dilemma, and that this level of thinking cannot solve the current
crisis.
We must incentivize 75 percent of people to move from the current
sick-care system to a self-pay, community-focused wellness system.
PREAMBLE: HOW WE GOT IN THIS SITUATION
1. The United States has a sick-care system, a disease-prevention
system, and a death-prevention system--all of this with great expense
and very little public satisfaction. (I cite an NIH official, Ezekiel
Emanuel, writing in JAMA, May 15, 2007.)
2. A 60-year focus on turning to experts to fix disease has
effectively taken away the capacity of the individual and the family to
know how to tend their own symptoms and diseases. The automatic
refrain, ``Ask your doctor before you do anything,'' has created a
massive feeling of impotency throughout the public.
3. This disempowerment of the public originates with the Flexner
Report in 1908; devised essentially at Johns Hopkins, the study
resulted in the closing of most other schools of healing by 1920. Thus
the ascendancy of what we currently call medicine was actually crafted
100 years ago in a process that greatly reduced the diversity of
healing options.
4. The longing for expert-based care was advanced by the
discoveries of antibiotics and blood transfusions and other
acknowledged miracles of modern medicine. It was assumed, as with many
other aspects of life, that everything could be made well by
technology. In the last quarter of the 20th century, this myth began to
recede; and now the plea of the American public is a simple call to the
medical profession: ``Please listen.''
5. Several studies at Tai Sophia indicate that even when symptoms
are relieved, patients often are not satisfied. Satisfaction is
correlated with ``I now understand how I control my symptoms.'' Having
an expert remove a headache is a vastly different experience than
having someone teach you how to change your own headache by drinking
more water, getting more sleep, breathing more deeply, or clearing an
upset. (The research of Nortin Hadler, M.D., Claire Cassidy, Ph.D., and
others underscore this observation.)
6. A root of this issue is an assumption long held in the medical
community that the mind and the body are separate, and that the
physical body can be dealt with separately from dealing with emotions--
a view that now is clearly unsustainable from a scientific perspective.
7. The situation for healthcare is similar to the issue of creating
a sustainable planet. Humans must learn to live appropriately and well
with our bodies, tending life as it is. In both cases, the issue is
sustainability.
8. Almost all existing conversations about health policy--whether
mainstream or complementary or integrative--focus inherently on
treating disease, preventing disease, and preventing death. All of the
economic incentives go to those who claim to tend these aspects of
healthcare; and insurance reimbursement is linked to the identification
of the disease being treated, the disease being prevented, or the
particular cause of death.
RESOURCES: BUILDING ON A MOVEMENT ALREADY WELL IN PLACE
1. The public is longing for empowerment to live well. This is
evidenced by a vast movement, especially among the wealthy, for access
to spas, wellness clinics, the use of complementary/alternative
medicine, and the use of yoga. This is a worldwide movement where
countries such as Thailand and India are positioning themselves to be
the future of wellness and medical care with a strong emphasis on
wellness.
2. The United States has an army of wellness providers in the form
of massage therapists, acupuncturists, herbalists, chiropractors,
wellness and holistically-oriented physicians and nurses. However,
because of the way funding works, most of these individuals do not
focus on promoting wellness, but are focused on promoting care
reimbursed by insurance within the existing system; thus, they are
diverted from their main interest of educating the individual on how to
be well.
3. This longing for learning about wellness and how to live well is
emphasized continuously on shows such as those by Montel Williams and
Oprah Winfrey, and through enormous sales of books by Andrew Weil,
Deepak Chopra, and Mehmet Oz, etc. The public longs for this kind of
learning.
4. There are demonstration projects. For example, the British
Government recently funded a project in Devon with Dr. Michael Dixon
and Simon Mills, who have devised a wellness program that gives local
primary care physicians funding incentives to invest in wellness, and
provides them the freedom to keep for the community any funding not
needed for disease-care. It is an inventive system to promote wellness
and to reduce the habit of turning to high-tech, higher cost
interventions.
5. Many of the components for an American wellness system are
available. They must be triggered by certain public policy steps to
redirect the way in which cash flows--a way of breaking the iron
triangle.
6. We break the iron triangle with a focus on a wellness system,
designed to move 75 percent of the public (a public that now repeatedly
goes to disease experts) into learning wellness practices--how to
breathe, how to sleep, how to exercise, and how to live well. It is a
conversation about what is not insurable. Wellness must be
incentivized, but we cannot insure well-living. We must figure out from
a public policy perspective how to encourage young children in the
first grade to breathe deeply, to get enough sleep, and to eat well.
For example, rather than immediately resorting to the pharmaceutical
Ritalin, we must learn how to incentivize deep breathing and exercise
for hyperactive children.
PUBLIC POLICIES
1. The President must use his ``pulpit'' to preach that healthcare
reform must start with an individual responsibility to live well using
wise habits: enough sleep, simple food, plenty of exercise, and leisure
time with family and friends. This seems to be the President's personal
lifestyle--focused not on preventing illness, but on wise habits
through which we feel good about being alive.
2. We must create a White House Office charged with promoting the
habits of wellness in every aspect of American life. Wellness is not
only a matter for the healthcare system; it must be developed through
the engagement of our educational system, our businesses, our
environmental awareness, our military families, our veterans services,
etc.
3. Fund demonstration initiatives in local communities, designed to
reduce medical expenditures when healthy lifestyle habits are
reinforced at a community level. Howard County, MD, currently has such
a demonstration project for the uninsured. These demonstrations should
provide financial and community-benefit incentives for corporations and
local governments to build wellness programs. Most self-insured
corporations and local governments and colleges have a financial self-
interest in promoting such initiatives. These wellness programs must be
incentivized with demonstration funding.
4. Funds provided for disease research must remain level, while
additional funds should be used to build and research a wellness model
for our society.
5. Wellness must not be insurance-linked. Insurance must be used to
tend pathologies when there are recognized ways to help. Tax-exempt
savings accounts may incentivize the transition from a disease model to
a wellness culture. (Nortin Hadler, at the Medical School at the
University of North Carolina, has written widely on this topic.)
6. All current healthcare providers must be trained to understand
their own bodies, i.e., how to maintain their own wellness. Most
healthcare workers endure extreme stress and are very vulnerable to
chronic illnesses. Like most Americans, healthcare workers tend to take
a pill in the presence of a headache rather than relieve the stress
that generated the headache.
7. This training for healthcare workers will effectively enable
each of them to become a wellness coach. As healthcare workers learn to
tend their own wellness, they will become a national army of wellness
educators able to instruct those who come to them, guiding them to
maximize their wellness and deal effectively with symptoms before their
symptoms become pathologies.
8. Individuals and families must learn to be their own primary care
providers. Our disease-oriented system will become more efficient as
people learn how to function with day-to-day symptoms and to manage
chronic disorders, and thus move out of this disease system. Thus,
demand for disease-care services will decrease, making access and
funding available for those who do need immediate care for a pathology.
9. The United States must fund the development of a series of
wellness universities (such as Tai Sophia) to train wellness educators
for our schools and our communities.
Senator Mikulski. Thank you, Bob.
Dr. Baase.
STATEMENT OF CATHY BAASE, M.D., GLOBAL DIRECTOR HEALTH
SERVICES, DOW CHEMICAL COMPANY, MIDLAND, MI
Dr. Baase. Good afternoon, Madam Chairwoman and members of
the committee.
I want to thank the committee for inviting me to discuss
integrative health as a means of health reform. I would like to
call your attention to the fact that I refer to this as
``health reform'' rather than ``healthcare reform'' so that we
keep the emphasis on health is what we are seeking, not so much
to continue what is currently a disease care system.
My name is Dr. Catherine Baase. I am the global director of
health services for the Dow Chemical Company and a board-
certified family practice physician responsible for Dow's
global occupational health, epidemiology, and health promotion
programs.
Dow has offered an employee occupational health program for
90 years, and we have had a formal, focused health promotion
program for more than two decades. We are recognized worldwide,
particularly for our leadership, innovation, measuring
outcomes, and operating a truly international health program.
In 2004, we developed a business case analysis related to
the health of Dow people that concluded that Dow's economic
impact associated with the health of Dow people exceeds $700
million annually. We spend nearly $300 million per year in the
U.S. on direct healthcare costs alone.
This is very significant in terms of cents per share. Our
U.S. healthcare spend is about 70 percent of what we spend on
research and development, and we illustrated the very real
opportunity to change that situation.
This business case drove development of a simple, yet
powerful corporate-level health strategy that is built on four
pillars--first, prevention; second, quality and effectiveness
of care; third, health system management; and fourth, advocacy
for these important principles.
The strategy reflects the alignment between the health of
our people and the success of our company. Our global approach
includes all elements of a comprehensive health promotion
program, including awareness, motivation strategies to engage
employees, skill-building programs, and supportive
environments.
Programs implemented since the onset of this health
strategy have been yielding positive results. For example, 75
percent of our U.S. employees voluntarily participate in health
assessments. Ninety-five percent report this as a highly valued
program. About 90 percent of U.S. employees participate in at
least one or more health programs each year.
Between 2004 and 2008, for our top risk factors--tobacco
use, physical activity, and obesity--we have seen a 15 percent
reduction in high-risk people and an 18 percent increase in
those at low risk. By 2013, with continued progress in just the
United States, we will have saved the company a cumulative $420
million over 10 years and will have contributed in the year
2013 10 cents per share.
Last, in 2007, one of our programs, our Health Advocacy
Case Management, yielded Dow a projected $11.7 million
advantage and saved the company more than 9,000 absenteeism
days. A key learning from the Dow health strategy is
recognizing that the health of our people is essential.
As a Nation, we do not focus on health outcomes. Every
dollar should seek maximum value. To broaden and sustain
workplace health programs, there are several steps the Federal
Government can take. For example, extending favorable tax
treatment for health and wellness programs would remove a major
barrier for other work sites.
The Partnership for Prevention, which Dow is a member of,
recommends additional specific actions. Some of these include
communicating better the benefits of health programs,
supporting research to evaluate and improve these programs,
creating an employer's health promotion resource center.
Finally, as you and your esteemed colleagues engage in
debate around the future of our country's health system, I
believe that worksite health programs like those at Dow are key
to ensuring that we reverse the trends of increasing health
risks and chronic disease for our citizens.
Thank you again, Madam Chairwoman and members of the
committee, for this opportunity. I look forward to answering
any questions.
[The prepared statement of Dr. Baase follows:]
Prepared Statement of Catherine M. Baase, M.D.
Summary
In the United States, we have what has been described as an
``illness'' care system--not a health system. As we work to reform the
``health'' system, we must be compelled by the fact the ``health'' of
our people is the critical outcome and the leading indicator of the
success. The money we spend on health is an investment in the
sustainable future of individuals, families and business enterprises.
Every dollar spent should deliver maximum value.
WORKPLACE HEALTH PROMOTION PROGRAMS
The role of employers in improving public health has received
minimal attention in health care reform discussions, even though the
potential for achieving a large-scale health and economic impact among
the group of employed, working-age adults is undeniable. Well conceived
workplace health promotion programs can improve employees' health,
reduce their risks for disease, reduce unnecessary health care
utilization, limit illness-related absenteeism, and reduce health-
related productivity losses.
THE DOW MODEL
The Dow Chemical Company has offered an employee occupational
health program for 90 years and has provided a focused health promotion
program for 20 years. The Company's approach has yielded global results
that have improved health and overall success of our business. After an
analysis of employee health in 2004, Dow's integrated approach to
health was strengthened by creation of a corporate Dow Health Strategy.
The strategy is focused on four elements: (1) Prevention, (2) Quality
and Effectiveness, (3) Health Care System Management and (4) Advocacy.
Positive results include:
Approximately 85 percent global employees and 75 percent
U.S. employees voluntarily participated in Dow health assessments.
According to satisfaction surveys from these participants, 95 percent
value the Dow health assessment.
About 75 percent of our people globally and 90 percent in
the United States participate in one or more internal Dow health
services each year.
Reduced health risks in our population, especially for our
top three risk targets of tobacco use, physical inactivity and obesity.
Between 2004 and 2008, we saw a 15 percent reduction of our employees
in higher risk health groups and a 18 percent increase of our employees
in lower risk health groups.
POLICY RECOMMENDATIONS
There are many steps government can take to encourage businesses to
implement workplace health programs and reward those that have them.
Extending favorable tax treatment for employer-contributions to pay for
employee health and wellness programs would remove a major barrier to
more widespread adoption of employee health and wellness programs and
lead to a healthier America. The Partnership for Prevention recommends
specific actions for local, State and Federal efforts, such as: better
communicate the benefits of workplace health programs, support research
to evaluate and improve them, create an employers' health promotion
resource center, recognize industry leaders; support research and
activities to improve and employ best practices; and provide tools and
resources to support health promotion efforts.
______
I. INTRODUCTION
Good afternoon Madam Chairwoman and members of the committee. I
would like to thank the committee for inviting me to testify today on
the subject of integrative health as a means of health reform,
particularly as it relates to businesses and workplace health promotion
programs. My name is Dr. Catherine Baase and I am a board-certified
Family Practice physician and the Global Director of Health Services
for The Dow Chemical Company. I have direct responsibility for
leadership and management of all Occupational Health, Epidemiology, and
Health Promotion staff and programs around the world. In addition to
these roles, I am deeply involved in the design and implementation of
Dow's Health Strategy for employees, retirees, and their families.
My testimony focuses on workplace health promotion programs, the
rationale for their adoption, Dow's positive experience with them and
policy recommendations that will expand their effective use and very
important public health impact. I hope to provide some insights on how
companies can provide successful, comprehensive health programs for
their people which result in healthy and enriched lives for individuals
while simultaneously delivering an improved economic impact to the
organization. Employee health and workplace health promotion programs
should be viewed and managed as strategic investments in the health of
populations, rather than simply costs. There are many ways that
government can support and encourage corporate health promotion
efforts.
At Dow, we have seen concrete results from our commitments to
workplace health promotion that advance our business goals, our
corporate social responsibility commitments and deliver highly valued
services to Dow people.
We are a proud leader in our national health discussion and believe
that health is of paramount importance to the success of individuals,
families and every enterprise--both private and public. As a company,
we care about our employees and their health is vital to us personally
and to the progress of our organizations.
I would like to acknowledge Garry Lindsay and the Partnership for
Prevention, and the staff of the National Business Group on Health, for
their assistance and contributions in compiling some of the information
related to health prevention and workplace health promotion programs.
II. HEALTH REFORM--THE ROLE OF THE WORKPLACE
We have in this country what has been described as an ``illness''
care system and not a health care system. We do not focus on health
outcomes. The dialogue and debate about the many ills of our health
care system has escalated in recent weeks because of the economic
crisis and the substantial funding for health included in the economic
stimulus bill that was signed into law last week. As implementation of
the stimulus bill's health provisions begins, it is vital that we keep
sight of the fact that the ``health'' of our people is the critical
outcome and leading indicator of the success of our expenditures. The
money we spend on health is an investment in our sustainable future and
intended to make people healthier. How much we spend or who has access
to our illness care system has limited meaning if we're not focused on
results and whether our health is sustained or improving. Every dollar
should seek maximum value.
From a results and outcomes perspective, the situation of our
current overall health is not a positive story. As an example, I'm sure
you have all seen the tremendously disturbing maps of our country as
they illustrate, over time, the dramatic epidemic of obesity. According
to the Centers for Disease Control, in 2007, only one State (Colorado)
had a prevalence of obesity less than 20 percent. Thirty States had a
prevalence equal to or greater than 25 percent; three of these States
(Alabama, Mississippi and Tennessee) had a prevalence of obesity equal
to or greater than 30 percent.\1\
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\1\ Centers for Disease Control, http://www.cdc.gov/nccdphp/dnpa/
Obesity/trend/maps/index
.htm.
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Health issues including obesity are among the broadest social
concerns we have. They affect every aspect of our lives--in our roles
as individuals, family members, citizens or business persons. From the
business perspective, based on data from the Towers Perrin Health Care
Cost Survey, we project average health care costs will increase 6
percent this year alone to an average total per employee cost of
$9,552. While the rate of growth is holding steady with prior year
increases, companies and their employees still face record-high costs
in 2009. Costs of this magnitude--and continuing increases above core
economic inflation--are clearly problematic, most especially now, in a
steep recessionary environment.
To put this in perspective, for an individual company like Dow, the
total economic impact (direct and indirect costs) related to the health
of our people exceeds $700 million annually. We spend nearly $300
million per year on direct health care costs in the United States
alone. From our 2007 summary, this was about 30 cents per share or 70
percent of what we spent on research and development.
From the cost of health care to the impact of worker health on
productivity, every business or enterprise clearly has a natural
alignment between the health of its people and its overall success. The
two are closely interwoven. So, it is of consequence there is now
consensus that current and future spending in employee health is
unsustainable, and poses a significant threat to the overall
competitiveness of American businesses within the global marketplace.
Recently, employers have implemented a number of approaches to
manage the supply of health care resources--and the demand--sometimes
through greater cost-shifting to the employee. However, leading
organizations have realized managing health benefit costs alone without
a balanced focus to ensure achievement of health outcomes is a matter
of dwindling returns.
One popular aspect of corporate health efforts is to focus on
primary prevention and risk avoidance, thus keeping the majority of the
workforce (and its dependents) low risk and healthy. Why is this the
case? First, a significant percentage of deaths in the United States
are associated primarily with modifiable, lifestyle-related behaviors.
Remarkably, more than one-third of total mortality is attributed to
three general risk factors: tobacco use, poor diet/low physical
activity (and their influence on obesity), and excessive alcohol
consumption.\2\ \3\
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\2\ Mokdad AH. Marks JS. Stroup DF. Gerberding JL. Actual Causes of
death in the United States, 2000. JAMA. 2004;291(10):1238-1245. (see
also Correction: actual causes of death in the United States, 2000.
JAMA. 2005;293(3):293-294.)
\3\ Flegal KM, Graubard BI, Williamson DF, et al. Excess deaths
associated with underweight, overweight, and obesity. JAMA.
2005;293:1861-1867.
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Beyond the quality of life impact, the annual social costs
associated with tobacco use and obesity are $192 billion and $117
billion, respectively. They are major risk factors for chronic health
conditions such as cardiovascular disease, chronic obstructive
pulmonary disease, cancer, and diabetes.\4\ \5\
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\4\ Christakis NA, Fowler JH. The spread of obesity in a large
social network over 32 years. N Engl J Med. 2007;357(4):370-379.
\5\ American Cancer Society. Smoking Costs United States $157
Billion Each Year. http://www.cancer.org/docroot/NWS/content/NWS_ 1_
1x_ Smoking_ Costs_ US_157_ Billion_
Each_Year.asp. Accessed February 14, 2009.
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Further, research is showing it is more cost-effective to invest in
preventive health practices, such as preventive screenings,
immunizations, health risk appraisals, behavioral coaching, and health
awareness/education, rather than spending resources exclusively on the
small minority of employees/dependents who are responsible for high-
cost health claims.\6\ This is not to say employers should neglect
high-cost employees. To the contrary, best-practice research is
demonstrating the total value of an integrated, population-based
strategy that addresses the health needs of all employees, dependents,
and retirees across the health continuum.
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\6\ Health Management Research Center. (2008) Cost Benefit Analysis
and Report 2008. University of Michigan, Ann Arbor, MI.
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A majority of employers report they have established some health
promotion efforts in the workplace. Regrettably, as reflected in the
findings of the 2004 National Worksite Health Promotion Survey, the
majority of employers have not implemented a successful strategy--only
6.9 percent of surveyed organizations met the criteria for a
comprehensive health promotion program.\7\ This is far short of the 75
percent target included in the Healthy People objectives for the
Nation, which shows there are still significant barriers to adopting--
on a large scale--worksite health promotion practices by organizations
both large and small.\8\ Research has demonstrated several elements are
required for the effectiveness of workplace health promotion efforts.
These are illustrated in the language of the proposed Healthy Workforce
Act which describes employers should have all four of the following
components in their health promotion programs: Awareness, Motivation
Strategies to Engage Employees, Skill Building Programs, and Supportive
Environments.
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\7\ Linnan L, Bowling M, Childress J, Lindsay G, et al. Results of
the 2004 National Worksite Health Promotion Survey. Am J Public Health.
2008;98(1):1-7.
\8\ U.S. Department of Health and Human Services. Healthy People
2010. 2nd ed. With Understanding and Improving Health and Objectives
for Improving Health. 2 vols. Washington, DC: U.S. Government Printing
Office, November 2000.
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For additional information, I direct you to the Partnership for
Prevention's workplace health promotion policy paper entitled Workplace
Health Promotion: Policy Recommendations that Encourage Employers to
Support Health Improvement Programs for their Workers which was
authored by Dr. Ron Z. Goetzel, Ph.D., Research Professor and Director,
Institute for Health and Productivity Studies, Emory University, and
Vice President, Consulting and Applied Research, at Thomson Reuters,
and his colleagues at the Institute for Health and Productivity
Studies, Emory University, Dr. Enid Chung Roemer, Ph.D., Rivka C. Liss-
Levinson, and Daniel K. Samoly.
iii. the rationale for corporate or workplace health promotion programs
In keeping health at the center of health reform, it is valuable to
review the determinants of health. Many similar analyses of these
factors are available. In the recent Shattuck Lecture article entitled
``We Can Do Better--Improving the Health of the American People'' by
Steven A. Schroeder, M.D., published in the New England Journal of
Medicine (NEJM), February 15, 2009, we see another poignant reminder of
the opportunities to improve population health.
Dr. Schroeder states, ``Health is influenced by factors in five
domains--genetics, social circumstances, environmental exposures,
behavioral patterns, and health care (Fig. 1). When it comes to
reducing early deaths, medical care has a relatively minor role. Even
if the entire U.S. population had access to excellent medical care--
which it does not--only a small fraction of these deaths could be
prevented. The single greatest opportunity to improve health and reduce
premature deaths lies in personal behavior. In fact, behavior causes
account for nearly 40 percent of all deaths in the United States.
Although there has been disagreement over the actual number of deaths
that can be attributed to obesity and physical inactivity combined, it
is clear these risk factors, along with smoking, are the top behavioral
causes of premature death. Clinicians and policymakers may question
whether behavior is susceptible to change or whether attempts to change
behavior lie outside the province of traditional medical care.'' \9\
---------------------------------------------------------------------------
\9\ Steven A. Schorder, M.D., ``We Can Do Better--Improving the
Health of the American People'' New England Journal of Medicine, 357;12
September 20, 2007.
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Of all the five domains of the determinants of health outcomes,
behavior patterns have the largest proportion of impact at 40 percent
while health care accounts for only 10 percent. As noted by Dr.
Schroeder, it is vital to have an effective mechanism to affect
behavior. Corporate health programs and worksite health promotion
represent an ideal opportunity to have impact on health behaviors for
adults and their families.\10\
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\10\ Steven A. Schorder, M.D., ``We Can Do Better--Improving the
Health of the American People'' New England Journal of Medicine, 357;12
September 20, 2007.
The role of employers in improving public health has received
minimal attention in discussions of health care reform, even though the
potential for achieving large-scale health and economic impact among
working-age adults is undeniable.\11\ After closely examining their
organizations' data, many large U.S. companies have concluded poor
health increases employees' utilization of health care services and
diminishes employee performance, safety, and morale. For a business,
workers in poor health, as well as those with behavioral risk factors,
mean greater medical expenditures, more frequent absenteeism, increased
disability, more accidents and sub-
optimal productivity.\12\ \13\ \14\ \15\ \16\ \17\ \18\ \19\ \20\
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\11\ Goetzel, RZ, Workplace Health Promotion: Policy
Recommendations that Encourage Employers to Support Health Improvement
Programs for their Workers. A Prevention Policy Paper Commissioned by
Partnership for Prevention. Washington, DC. December 2008.
\12\ Goetzel RZ, Long SR, Ozminkowski RJ, Hawkins K, Wang S, Lynch
W. Health, Absence, Disability, and Presenteeism Cost Estimates of
Certain Physical and Mental Health Conditions Affecting U.S. Employers.
Journal of Occupational and Environmental Medicine. 2004;46(4):398-412.
\13\ Anderson D, Whitmer R, Goetzel R, et al. The relationship
between modifiable health risks and group-level health care
expenditures: A group-level analysis of the HERO database. American
Journal of Health Promotion. 2000;15(1):45-52.
\14\ Goetzel RZ, Jacobson BH, Aldana SG, Vardell K, Yee L. Health
Care Costs of Worksite Health Promotion Participants and Non-
Participants. Journal of Occupational and Environmental Medicine.
1998;40(4):341.
\15\ University of Michigan. The Ultimate 20th Century Cost Benefit
Analysis and Report. 2000:45-52.
\16\ Mercer Human Resource Consulting. National Survey of Employer-
Sponsored Health Plans--Survey Highlights. http://www.mercerhr.com/
referencecontent.jhtml?idContent=1258
390. July 3, 2006.
\17\ Mercer Human Resource Consulting. Mercer/Marsh Survey on
Health, Productivity, and Absence Management Programs. http://
www.mercerhr.com/pressrelease/details.jhtml/dynamic/idContent/1231700.
July 12, 2006.
\18\ Goetzel RZ. Examining the Value of Integrating Occupational
Health and Safety and Health Promotion Programs in the Workplace.
Department of Health and Human Services, Public Health Services,
Centers for Disease Control and Prevention, National Institute of
Occupational Safety and Health, 2005:1-61.
\19\ Goetzel RZ, Juday TR, Ozminkowski RJ. What's the ROI? A
Systematic Review of Return-On-Investment Studies of Corporate Health
and Productivity Management Initiatives. AWHP's Worksite Health.
1999;6(3):12-21.
\20\ Goetzel RZ, Hawkins K, Ozminkowski RJ, Wang S. The Health and
Productivity Cost Burden of the ``Top 10'' Physical and Mental Health
Conditions Affecting Six Large U.S. Employers in 1999. Journal of
Occupational and Environmental Medicine. 2003;45(1):5-14.
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Over the past 30 years, many enlightened employers have put in
place comprehensive, multi-component health promotion programs. They
have come to appreciate the important role these programs play in
improving the health and well-being of their workers, which in turn can
increase worker productivity and improve benefit costs.\21\ Many of
these employers also believe health promotion programs can
significantly influence an organization's ability to attract and retain
top talent who are drawn to a healthy company culture which encourages
a work-life balance.\22\ In fact, some employers have made employee
health promotion initiatives part of their overall emphasis on
sustainability and corporate social responsibility.\23\
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\21\ Linnan L, Bowling M, Childress J, et al. Results of the 2004
National Worksite Health Promotion Survey. American Journal of Public
Health. 2008;98(1).
\22\ Wolfe R, Parker D, Napier N. Employee Health Management and
Organizational Performance. The Journal of Applied Behavioral Science.
1994;30(1):22-42.
\23\ Health Enhancement Research Organization. http://www.the-
hero.org/. August 4, 2008; and Goetzel R, Ozminkowski R. The Health and
Cost Benefits of Worksite Health Promotion Programs. Annual Review of
Public Health. 2008;29:303-323.
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Dow believes any reform of our health care system must contain a
broad approach to prevention which incorporates clinical preventive
services, public health and community-based interventions. As a vital
component of a true ``health'' system, companies can make a positive
difference in the health of their people, and can have a peripheral
impact in the communities where they operate. Well-conceived workplace
health promotion programs can improve employees' health and quality of
life, reduce their risks for disease, control unnecessary health care
utilization, limit illness-
related absenteeism, and decrease health-related productivity losses.
The worksite is the right place to tackle many of our health
problems because adults spend so much of their active, waking hours at
work. As Dr. Goetzel points out, health promotion programs make sense
because:
Workplace programs can reach large segments of the
population not exposed to and engaged in organized health improvement
efforts;
Workplaces contain a concentrated group of people who
share common purpose and culture;
Communication with workers is straightforward;
Social and organizational supports are available;
Certain policies, procedures and practices can be
introduced and organizational norms can be established; and
Financial or other types of incentives can be offered to
gain participation in programs.\24\
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\24\ Testimony of Ron Z. Goetzel, Ph.D., before the House Armed
Services Committee Subcommittee on Military Personnel, March 12, 2008.
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Further, there is a logical basis for workplace health prevention:
1. Many of the diseases and disorders are preventable;
2. Many of these diseases and disorders are triggered by modifiable
health risks;
3. Many modifiable health risks are associated with increased
health care costs and decreased worker productivity;
4. Modifiable health risks can be improved through health promotion
and disease prevention programs;
5. Improvements in the health risk profile of a population can lead
to reductions in health care costs and absenteeism, and heightened
productivity; and
6. Well-designed and well-implemented worksite health promotion and
disease prevention programs can save money and produce a positive
return on investment (ROI).\25\
---------------------------------------------------------------------------
\25\ Testimony of Ron Z. Goetzel, Ph.D., before the House Armed
Services Committee Subcommittee on Military Personnel, March 12, 2008.
In over three decades of research, the University of Michigan
Health Management Research Center (HMRC) has demonstrated the
association between health risks and excess health and productivity-
related costs. As Charts 2 and 3 (from the HMRC) illustrate, increased
health risks equate to higher health care costs, whereas reduced health
risks equate to lower overall costs. Simply put: costs follow
risks.\26\
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\26\ Health & Vitality Ink Communications. The Case for Health
Promotion Programs. 2002.
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CHART 3
The HMRC has demonstrated the same associations between health-
related risks and productivity-related costs attributed to disability,
workers' compensation, and presenteeism. The HMRC has also shown excess
health risks (e.g., three or more co-morbid health risks such as
inactivity, excess body weight, and tobacco use) are independent of the
cost burden of chronic disease. In other words, excess health risks
further compound the total cost burden of managing chronic health
conditions such as chronic obstructive pulmonary disease, diabetes, and
heart disease.\27\
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\27\ Health Management Research Center. (2008) Cost Benefit
Analysis and Report 2008. University of Michigan, Ann Arbor, MI.
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It is important for organizations to address not only high-cost
groups (e.g., heart disease, asthma, diabetes) through such
interventions as disease management programs, but also address ``at-
risk'' groups who exhibit modifiable risk factors (e.g., obesity, low
physical activity, poor diet, tobacco use) which are associated with
chronic health conditions and further exacerbate their management once
diagnosed.
Today, there is sound evidence that investing in workplace health
promotion programs provides organizations with a number of financial
incentives which not only addresses escalating health care costs, but
also provide a productivity management strategy. From the HMRC, we see
(in Chart 4) the typical organizational profile of the economic impact
of the health of a corporate population.
Consider the following:
The HMRC estimates an organization saves $350 annually when a low-
risk employee remains low risk, compared to a savings of $153 when a
high-risk employee's health risks are reduced.\28\
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\28\ Edington DW. Emerging research: a view from one research
center. American Journal of Health Promotion. 2001:15(5)341-349; and
University of Michigan Health Management Research Center. The Worksite
Wellness Benefit Analysis and Report. 1979-2004;7-15.
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One meta-review of 56 published studies of workplace health
promotion programs shows \29\:
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\29\ Chapman LS. Meta-Evaluation of Worksite Health Promotion
Economic Return Studies: 2005 update. The Art of Health Promotion.
2005;19(6):1-11.
Average 27 percent reduction in sick leave absenteeism;
Average 26 percent reduction in health care costs;
Average 32 percent reduction in workers' compensation and
disability management claims costs; and
Average $5.81 to $1 savings-to-cost ratio.
The question about return on investment for health promotion or
prevention efforts has long been debated. I would like to bring to the
attention of the committee the work of Dr. Steven Woolf in the February
4, 2009 issue of the Journal of the American Medical Association
(JAMA), titled, ``A Closer Look at the Economic Argument for Disease
Prevention.''
Dr. Woolf states,
``The question of whether prevention saves money is
incorrectly framed. Health care, like other goods, is not
purchased to save money. The dollar can be stretched further--
more goods can be acquired--by optimizing economic value. The
proper question for a preventive (or therapeutic) intervention
is how much health the investment purchases. . . . Prevention
accounts for only 2 percent to 3 percent of health care
expenditures. . . . Disease care is the dominant driver of
health spending, and yet it evades the economic scrutiny
applied to preventive services. . . . The same questions posed
for prevention must now be applied to disease treatments: does
the intervention improve health outcomes, and how strong is the
evidence? If the intervention is effective, is it cost-
effective (a good value)? Can other options achieve better
results, or the same results at lower cost? Throughout health
care, the spending crisis requires a comprehensive search for
ways to shift spending from services of dubious economic value
to those with high cost-effectiveness or net savings. Whether
those services are preventive or otherwise is not the point;
what matters is prioritizing services that produce the greatest
health benefits for the dollars spent. In that context it makes
sense to invest in a well-defined package of preventive
services that are effective and offer good economic value.
Services that yield net savings--whether prevention or
treatment--are priorities.'' \30\
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\30\ Steven Woolf, M.D., M.P.H., ``A Closer Look at the Economic
Argument for Disease Prevention,'' Journal of the American Medical
Association. 2009;301(5):536-538 http://jama.ama-assn.org/cgi/content/
full/301/5/536.
This article extracts and reinforces information developed in a
white paper, ``The Economic Argument for Disease Prevention:
Distinguishing Between Value and Savings,'' by Dr. Woolf, Corinne G.
Husten, M.D., M.P.H., Lawrence S. Lewin, James S. Marks, M.D., M.P.H.,
Jonathan Fielding, M.D., M.P.H., M.B.A., and Eduardo Sanchez, M.D.,
M.P.H., on behalf of Partnership for Prevention's National Commission
on Prevention Priorities. This white paper is accessible on the Web
site: http://www.prevent.org/images/stories/PolicyPapers/
prevention%20cost-effectiveness.pdf.&
At Dow, we have adopted this investment focus and health outcomes
approach because the health of our company depends on the health of our
people. The health of Dow's employees, their families and the
communities in which we operate is a strategic priority and is seen as
essential to the company's sustainability. One of Dow's four strategic
themes is to ``build a people-centric performance culture.'' This means
attracting and retaining the most talented people from throughout the
world, developing them, and rewarding them for the results they achieve
with the goal of driving both personal and company success. Worksite
programs are in many ways, an embodiment of our people-centric
performance culture.
This is the rationale for workforce health programs: company health
depends on employee health and there are clearly identifiable areas we
can target to improve health, while at the same time reduce costs and
improve productivity.
iv. the dow model
Dow has offered an employee occupational health program for 90
years and has had a focused health promotion program for more than 20
years. Dow has been recognized worldwide in the field of corporate
health programs--particularly for its leadership, innovation and
measurable outcomes. A few years ago, at the request of our CEO and
executive team, we developed a business case analysis of our situation
related to the health of Dow People. A simplified summary of the
business case is:
Dow has a very large economic impact associated with the
health of our people,
Translating this economic impact to cents/share
demonstrates it as a significant priority,
There is strong evidence that we have an opportunity to
change the situation through improved quality, addressing waste and
ineffectiveness in the system and through prevention,
Health advocacy is a priority as reform agendas are vital
to the future.
This business case drove development of a simple yet powerful
corporate level health strategy. Our CEO, Andrew Liveris, continues to
be a strong advocate both internally and externally to Dow on the
importance of health.
Dow's health strategy is built on four pillars: (1) Prevention; (2)
Quality and Effectiveness; (3) Health System Management; and (4)
Advocacy.
The strategy includes all aspects of the impact of health for ``Dow
family'' members (including employees, dependents and retirees). It is
reflective of our belief in the alignment between the health of our
people and the success of our company.
Based upon a long-term commitment, we have set multi-year goals as
well as annual objectives for each pillar of the strategy.
To put this in bottom-line value for our company, our initial
business case estimates illustrated that if we could keep our U.S.
direct dollars in the lower end of projected inflation vs. the higher
end, this alone would be worth 7 cents per share, which would be over
$50 million in 2008 (by comparing project spending at the lower
inflation vs. average company experience). By 2013, if we can continue
our progress to the ``best performer'' level, we anticipate we will
have saved the Company a cumulative $420 million over 10 years, and
will contribute 10 cents per share in 2013.
Through studies, we estimated that by improving our primary health
risk factors by just 1 percentage point each per year, we would save
$62 million in U.S.-direct health care costs over 10 years. In studying
the literature, I believe there is a real opportunity for improvement
in safety, quality and effectiveness in health care which will lead to
better health outcomes and much higher value for the dollar spent. It
is commonly noted as much as 30 percent of health expenditures are
unnecessary. Sophisticated purchasing, strong accountability,
innovation and collaboration in our communities all represent further
opportunities.
Driven by our 2004 strategy, many of our recent program dimensions
are still young, but we are encouraged by the indicators of the
positive health impact we are seeing already. Let me share a few from
just the last couple years.
We have seen increases in the percent of Dow people who
believe Dow sincerely cares about their health and well-being. Using
global assessments, we again saw an improvement of 2 percent in 2007
versus 2005 in employee perceptions.
Approximately 85 percent of global employees and 75
percent of U.S. employees voluntarily participate in health
assessments. According to satisfaction surveys, 95 percent value this
option--which is why we are able to attain such high participation
rates without direct financial incentives to participate.
About 75 percent of our people globally and 90 percent in
the United States participate in one or more internal Dow health
services each year.
We are reducing health risks in our global employee
population especially for our top three risk targets of tobacco use,
physical activity and obesity. Between 2004 and September 2008, we saw
a 15 percentage point reduction in high-risk people and an 18
percentage point increase in low-risk people in these three categories.
Using an established baseline of global employees from
2004, we have seen a decrease in the high-risk level for four out of
eight health-risk factors. Over this same period from 2004 through
September 2008, we have increased the number of employees in the low-
risk category in seven of the eight measures.
Through increased awareness and enhanced benefits
coverage, Dow's U.S. colorectal screening has improved 12 percent since
January 2007 to 56 percent, slightly above the HEDIS (Healthcare
Effectiveness Data and Information Set) benchmarks reported by the
National Committee for Quality Assurance (NCQA) which represent
national thresholds for commercially insured populations.
Using U.S. data, we can illustrate the impact of just one
of our key services, health advocacy case management, in total economic
benefit ($11.7 million) and absenteeism days saved (9,232) in 2007.
Focusing on the prevention health aspect of our strategy, our
comprehensive health promotion program incorporates the best practice
design and implementation characteristics mentioned earlier: Awareness,
Motivation Strategies to Engage Employees, Skill Building Programs, and
Supportive Environments. It includes a variety of health-related
company policies and initiatives. They include: health screening,
consultation, referral and follow-up, health education through intranet
and internet channels, small group programs, health/disease risk topic
focused campaigns, on-site wellness centers, self-care and consumer
education, and tools such as the launch of an electronic personal
health record. In addition, we offer strong prevention coverage in our
health benefit plans, as well as initiatives to create a supportive
environment such as our Healthy Workplace Index released in 2007. Our
global strategy features corporate efforts and local plans to ensure we
meet the needs of Dow's diverse workforce; and it emphasizes shared
responsibility between the company, local leadership and employees for
improved health.
Reducing Tobacco Use: The Dow Corporate Smoking Policy was first
enacted in the United States in 1993. It has been updated and since
January 1, 2003, all Dow property and meetings are smoke-free. Outside
of the United States, all Dow buildings and meetings have been smoke-
free since January 1, 2004. The difference in the two policies
represents the necessity for utilizing a multicultural approach. The
global policy was written as a minimum standard with room for
flexibility in actualizing it. Our programming also leverages company-
wide energy, while encouraging value-adding localization.
One example is Dow's annual No Tobacco Day, which urged tobacco
users to make a commitment to quit using tobacco for at least one day.
Communicated in 15 languages across all Dow sites globally, tobacco
users were asked to commit online. Participants received motivational
messages and the chance to win gift card prizes (valued approximately
$50-$200). In the inaugural year, 6 percent of tobacco users
(representing 27 different countries) committed to quit and 56 percent
met the 24-hour challenge. At 6 months, 11 percent of surveyed
participants remained tobacco-free. Site leaders from 30 sites also
committed to making their work environment more supportive and
sponsored activities like tobacco cessation workshops, tobacco-free
worksites, free ``cold turkey'' lunches, educational sessions for
employees' families, and free massages. In 2008, 434 Dow people from 21
countries committed to quit using tobacco during this event; 47 percent
were successful for the 24-hour challenge.
Eliminating the negative impacts of tobacco use requires more than
just a policy and program. As part of our comprehensive approach, we
have strengthened our internal health counseling efforts and improved
our U.S.-medical benefit plan to cover tobacco cessation consultation
and pharmacotherapy at 100 percent, using evidence-based, best practice
recommendations from the National Business Group on Health and U.S.
Preventive Services Task Force. After more than 5 years of a stagnant
tobacco use rate of 18 percent, tobacco use has dropped 2 percentage
points to 16 percent, in the last 2 years.
Increasing Physical Activity: Dow implemented a global year-long
physical activity challenge, MOVE for Good Health, to increase emphasis
on regular physical activity at both an individual and organizational
level. Nearly 5,000 people from 53 countries registered for MOVE and
made sustained changes in their physical activity level:
89 percent of previously sedentary participants became
active (i.e., were sedentary at baseline and now exercise at least once
per week);
47 percent of high-moderate risk participants moved into
low risk during the program (i.e., started at high or moderate risk and
now exercise three or more times per week); and
MOVE contributed to a 2008 Dow global population
improvement in physical activity level--a 1 percentage point reduction
in high risk (from 26 percent to 25 percent) and 1 percentage point
increase in low risk (from 39 percent to 40 percent).
Since 2005, efforts to improve access to physical activity at Dow
worksites, global physical activity challenges, and partnerships with
groups like the U.S. President's Council on Physical Fitness and Sports
have helped support a 7-percent increase in our low-risk population and
a 10 percent reduction in high risk for physical activity in the United
States alone. Globally the improvements were 14 percent and 11 percent,
respectively.
Impacting Overweight and Obesity Issues: Dow is participating in
National Heart, Lung, and Blood Institute (NHLBI) funded research to
examine the health and economic benefits of worksite and environmental
interventions on overweight and obesity. The environmental
interventions, called LightenUP, aim to decrease unhealthy eating and
increase physical activity among workers and include:
Moderate-level treatments which introduce relatively
inexpensive environmental changes to the physical environment, such as
walking paths, healthy food choices, nutritional information in vending
machines and cafeterias, and employee recognition;
More intensive-level treatments encourage an
organizational culture of healthy behaviors through leadership
training, top management involvement, integration of behavior change
programs into the company's established business practices and
leadership accountability; and
Control sites continued to receive the core health
promotion programs, including individual-based programming (e.g.
counseling), but did not receive the environmental interventions.
After 1 year of the study, researchers found employees who
participated in the LightenUP interventions reduced their blood
pressure risk and maintained a steady weight when compared to employees
at control sites who received only individual-focused interventions.
After 2 years, we are seeing an increase in physical activity, better
nutrition habits, reduction in tobacco use, increase in leadership
support and increase in employee awareness. These results suggest even
moderate changes to the work environment can have a positive impact on
employees by reducing at least one health risk and helping the well
stay well. Preliminary analysis of our year three data indicates some
significant results. It appears average weight loss at the intervention
sites was significantly greater than at control sites, as were the
reductions in mean blood pressure and cholesterol levels. Intervention
sites also achieved significantly greater improvements in diet and
exercise. These results indicate adding environmental interventions to
individual-level programs improve biometric and behavioral risk
factors.
In addition, to addressing modifiable risk factors, Dow health
promotion efforts engage employees, retirees and family members as
active participants in their health care. Dow's Positive Action health
care consumerism program increased awareness of the consumer's role,
helped participants become more comfortable with the U.S.-health care
system and taught valuable skills such as self-care and adequately
preparing for a doctor's visit. In the 9 months following the program
pilot, participants experienced fewer health care claims than non-
participants, which equated to a half million dollars in savings to
employees and approximately $300,000 in savings to Dow within the first
year after the program.
The success of The Dow Chemical Company in establishing and
maintaining a global culture of health can be seen as a systematic
process. The support of leadership is unquestionably ingrained and the
health of employees is directly linked to business goals and
objectives. This approach and strong focus on prevention translates to
comprehensive worksite health promotion which is uniquely tailored to
Dow employees. I'm proud to report Dow is one of the few companies
which have shown a global approach is not only possible but successful
as well.
Community Impact
Beyond our employees and their families, Dow has a longstanding
commitment to the health of the communities in which we operate, which
can be traced back to Founder Herbert H. Dow.
Over the years, Dow has worked hard to establish:
Employee health programs which are recognized for their
excellence;
Community advisory panels at all major production
locations;
Direct financial contributions to health needs in
communities as an integral part of corporate giving;
Medical departments at major sites which work closely with
local community health services; and
Public health value because we perform and publish
important health research.
One example of community partnership is Dow's investment to help
establish the Michigan Health Information Alliance, MIHIA, a multi-
stakeholder collaborative covering 11 counties in central Michigan
which is dedicated to improving the health of the people in the region
through the innovative use of health information. MIHIA is also a
Chartered Value Exchange as designated by the Department of Health and
Human Services through the Agency for Healthcare Research and Quality.
Aligned with the mission is a commitment to advance the cornerstones of
value-driven health care through the development and implementation of
interoperable health information technology, and the dissemination of
price and quality information.
Another example is Dow's funding and leadership to build a
community YMCA in Plaquemine, LA near one of our sites. In each case,
Dow targeted its investment with community needs which also aligned
with our Health Strategy--using the broader community to help create a
more supportive environment for the health of Dow people and support
the entire community.
Over the course of our efforts, we have learned many lessons which
may be useful to any business undertaking workplace health programs:
Establish the entire effort upon a principle of serving
the best health outcomes for individuals and maintain integrity with
this throughout every aspect of operation. It builds trust which is
invaluable to long term success.
The creation of a business case is essential to secure
management commitment.
Determine the total economic impact of all health-related
costs both direct and indirect.
Establishment of a corporate strategy is essential.
It is imperative to have a long-term view and commitment
for the health strategy.
Companies should establish a measurement strategy to set
priorities and track outcomes.
Creation of internal partnerships of related functional
groups is a success factor.
Implementation strategies should include individuals and
small groups.
Inclusion of cultural considerations.
Efforts must align to company business priorities.
Understand the role of all stakeholders including labor
organizations in achieving success.
Ensure absolute privacy and confidentiality of all
personal health data.
Program/services design and implementation must be
culturally sensitive.
Companies should develop and adhere to a clearly
documented operating discipline which is supported by all applicable
functions within the organization.
These results affirm the value of our specific efforts and of
corporate health programs generally. With a sustained focus, we will
continue to have an impact on the health of our people, because
corporate health strategies offer one of the best opportunities to
effectively engage adults to maintain and improve health.
V. POLICY RECOMMENDATIONS
There are many steps government can take to encourage businesses to
implement a workplace health program and reward those that have them.
Health policy groups, business groups and their combined coalitions are
working to provide constructive policy recommendations in this arena.
For example, Dow has joined with a number of companies and
associations, through the Workplace Wellness Alliance which is
sponsored by the U.S. Chamber of Commerce and the Partnership for
Prevention in an effort to encourage the Federal Government to enact
legislation and regulations supporting employer-based wellness
programs.
First, I believe a change in tax policy is needed to improve
employee wellness and reduce obesity. The current tax treatment of
wellness, fitness, health promotion, and weight management programs for
employees poses a barrier and disincentive to more comprehensive
employer-sponsored wellness programs.
While current tax law allows employers to deduct all of their costs
toward employee wellness as business expenses, generally, the value of
employer contributions to employees for these purposes must be reported
as income subject to taxation by employees--including payment for
fitness, nutrition, and weight management programs. Only employees for
whom these programs and activities are required or prescribed as part
of treatment for medical conditions--including medical obesity--do not
have to report employer contributions as taxable income. Current tax
law also does not allow employees to use pre-tax dollars to pay for
fitness facility fees, exercise programs, nutrition classes, or weight
management classes unless they are prescribed or required as part of
treatment regimens for medical conditions. In other words, our current
tax code provides tax incentives for medical care and treatment but
does not provide tax incentives for maintaining health and wellness.
Furthermore, the complicated tax requirements create an
administrative burden for employers who are trying to do the right
thing by offering health and wellness programs to employees. Employers
who pay for these services on behalf of their employees must determine
for which employees their contributions are considered taxable income
and for which employees they are not taxable, raising health
information privacy issues along with the extra administrative burden.
The solution: Extending favorable tax treatment for employer-
contributions to pay for employee health and wellness programs would
remove a major barrier to more widespread adoption of these programs
and lead to a healthier America.
Consider the following:
Employees should be able to use pre-tax dollars (including
through section 125 cafeteria plans, HSAs and FSAs) to pay for health
and wellness activities, programs and purchases including fitness,
nutrition, and weight-management programs.
Employer contributions toward employee expenses for health
and wellness, activities, programs and purchases should be excludable
from income for tax purposes.
People should be allowed to deduct any post-tax out-of-
pocket expenses for health and wellness activities, programs, and
purchases from their taxes (irrespective of whether it is for medical
treatment or for wellness, health maintenance and disease prevention
and whether or not their total health care expenses are below the 7.5
percent adjusted gross income threshold).
Additionally, I want to share recommendations from the Partnership
for Prevention with you because they are based on the central premise
which supports all workplace health programs: keeping people healthy
contains costs and increases productivity. Many of the recommendations
are geared towards the development, promotion and adoption of best
practices workplace health programs.
1. Better communicate to employers the benefits of workplace health
programs.
Innovative approaches are needed to communicate to employers the
economic costs associated with poor health, the options available to
reduce health risks, and the cost savings and productivity gains
possible through workplace health programs. Federal, State, and local
health agencies, alone and in partnership with businesses, should
leverage their extensive marketing and communication networks to share
information about exemplar health programs to employers that have
meager or non-existent programs.
2. Increase funding for research to evaluate and improve workplace
health programs.
There has been some government funding support for evaluating
workplace health programs, but most research in this area has come from
the private sector. As a result, our current data and understanding are
limited. More government support is needed for studying the science
underlying workplace-based programs and the effectiveness of these
programs in improving health, lowering costs, and increasing
productivity. We also need translational research so these programs can
be adapted for businesses of all types and sizes.
3. Develop tools and resources to support employer workplace health
programs.
Several tools and resources for workplace health promotion have
already been developed and disseminated with the support of government
funding, but more tools and resources are needed to help employers
design, implement, and evaluate their programs. These tools will enable
employers to establish their case for health promotion programs,
identify partners, and evaluate their program's outcomes.
4. Pilot innovative health promotion programs at Federal, State, and
local departments and agencies.
Most government agencies have not implemented evidence-based health
programs for their own employees and dependents. By doing so, they can
not only function as role models for private sector businesses but they
can function as experimental employer laboratories providing models of
successful program execution other public and private organizations can
emulate.
5. Honor and reward America's healthiest organizations.
Government programs to recognize and reward innovative companies
and organizations which have successfully implemented health promotion
programs should be expanded. Greater recognition and prestige for
businesses demonstrating effective leadership in health promotion will
elevate their stature as innovators in the field. To stay competitive
to attract and maintain top talent, other businesses will take notice
and adopt or enhance their own workplace programs.
6. Create an employers' health promotion resource center.
A government-supported resource center would collect, develop, and
disseminate objective, easy-to-use, and accessible workplace health
promotion information and act as a clearinghouse for resources, tools,
and expertise to support employer efforts. Employers could then judge
the relative merits and cost-effectiveness of alternative health
promotion models.
7. Establish a public-private technical advisory council.
Many large employers can afford to hire expert consultants who help
them structure effective programs, but smaller employers often cannot.
A public-private technical advisory council would draw upon the
expertise of private consultants and experts in government who would
volunteer their time to support employers wishing to implement health
promotion programs. The council could be set up in a similar fashion as
other government advisory panels, such as the U.S. Preventive Services
Task Force.
8. Establish collective purchasing consortia for small employers.
Federal agencies should establish collective health promotion
purchasing consortia, similar in design to multi-employer trusts, which
would define common health and business objectives for employers in a
given community, achieve consensus on health program designs, issue
requests for proposal to vendors and health plans, support the
establishment of performance guarantees related to the success of these
programs, and help ensure evaluations which can be used to enhance
programs.
9. Support establishment of workplace health program certification
and accreditation programs.
Several established review and accreditation organizations, such as
the National Committee for Quality Assurance, have introduced review
processes focused on workplace health programs and their vendors to
objectively assess their quality. Support of these accreditation and
certification initiatives will help establish minimum standards for
quality and performance against which vendors and others engaged in
implementing workplace programs are held. In turn, these initiatives
will spur program improvements and encourage more companies to enhance
or initiate programs.
In addition to these ``best practices'' promoting recommendations,
there are additional ways government can accelerate the adoption of
workplace health programs. Tax incentives for introducing or expanding
workplace health programs can accelerate the adoption of workplace
programs. Such incentives are important because many businesses,
particularly in the current economic environment, consider workplace
health programs to be cost prohibitive. Tax incentives would encourage
more employers to adopt workplace health programs as part of their
business strategies.
VI. SUMMARY
As the Nation moves into the full-fledged debate about the future
of health care, it is imperative we consider all possible options to
keep Americans well. Worksite health programs, such as those
implemented by Dow around the world, are key components of empowering
people to take control of their health.
We know our employees are the foundation of our company. As we
implement our Dow Health Strategy to seek the best health outcomes for
our people, we keep the company in good health. Worksites offer one of
the best opportunities to effectively engage adults to maintain and
improve health, and Dow has demonstrated that establishing and
maintaining a culture of health in the workplace is possible. We look
forward to working with you and other public and private sector leaders
to improve and expand workplace health promotion programs. With
sustained focus we will continue to have a positive impact on the
health of our people.
ABOUT DOW
Dow was founded in Michigan in 1897 and is one of the world's
leading manufacturers of chemicals and plastics. We supply more than
3,300 products to customers in 160 countries around the world,
including hundreds of specialty chemicals, plastics, agricultural and
pharmaceutical raw materials for products essential to life. About half
of our employees are in the United States, and we help provide health
benefits to more than 34,000 retirees in the United States.
Senator Mikulski. Well, I want to thank the participants
and also acknowledge again our resource people, all of whom
submitted papers. I am going to ask unanimous consent that they
be included in the record.
[The information previously referred to may be found in
Additional Material.]
Senator Mikulski. Now let me talk about this something
called ``the committee'' here, and then we will go to my
questions. You might have a question of us, like where is
everybody?''
[Laughter.]
That is a good question. Just a few days ago, Senator Reid
announced that there would not be any votes today. So my
colleagues extended their time in their States, where they are
out listening, as I have during the last week, to our
constituents.
What I want you to see up here is every one of the
Democratic Senators has a staff person here. Of course, someone
that I have collaborated with on these issues, Senator Harkin,
has his team here, as does Senator Kennedy.
Also there, as you can see on the other side, there is
Republican participation. So there is something called ``the
Committee.''
This is also being recorded not only officially, as we do
at every hearing, but the Senate recording studio, a
bipartisan, nonpartisan group, is recording this. We will have
videos and DVDs available for those who might want to use it
for teaching and public policy or to review what we talked
about.
We would like to get it over to the IOM because we think we
are pretty hot.
[Laughter.]
Or pretty cool, depending. But we are anti-inflammation.
[Laughter.]
Now, when I discussed the idea of having this hearing with
many of you and I discussed it generally with some of my
committee, and also I know there was some staff reaction. We
have a long way to go. Some of us knew a lot about it. Some of
us knew very little about it. Some were worried was this just
one more--was this some kind of gaga approach? Sister, you
referred to from going to exotic and mainstream.
One of the testimonies talked about children. We focus
sometimes on giving Ritalin to children who really have certain
problems of agitation in the classroom, and nobody would bat an
eye or ask a question. If concepts like deep breathing, yoga,
even conflict resolution in the classroom were introduced, it
would raise eyebrows not about what is going on in a negative
sense, but what is this? It might even be regarded as laughable
and dismissed.
Well, I don't think these things are a laughing matter.
That is what the focus of this hearing is. I am going to ask
some naysayer questions for a minute so that we can kind of get
that out into the sunshine as we do it.
Now one of the things each and every one of the panelists--
and I must say every one of these presentations was so content
rich, but one was the recommendation for an Office of Wellness
and Prevention at the White House, kind of like a wellness
czar, which is a phrase I don't want to use.
My question would be this--and I throw it to anyone on the
panel and even the resource committee to comment. Don't we have
a surgeon general? If we don't, shouldn't we have a surgeon
general? Shouldn't that be the job of the surgeon general to be
the promoter of health and wellness? Why do we need another
office?
Oh, don't we have a Centers for Disease Control? Isn't that
what they are supposed to be, not only the forensic sleuths for
undetected and undisclosed--you know, their fabulous work in
finding Legionnaire's Disease and these others?
It is the Centers for Disease Control, and aren't they
supposed to take what the gurus at NIH come up with and kind of
get it out there and so on? Why do we need a new White House
thingamajig? Shouldn't we have a surgeon general, and shouldn't
we have a CDC? And aren't we just duplicating it or--I will
stop there.
Dr. Gordon, you were right out of the box.
Dr. Gordon. I am ready to talk about that. You know, I
think there may come a time when we won't need one. Right now,
there needs to be a spotlight on this issue. The CDC and the
surgeon general have very specific purviews, and they have very
little authority over any other agency.
We need somebody, some office that is going to really keep
an eye and make sure that what is put forward here in Congress,
what is put forward by the Administration, actually is enacted.
We had experience with the White House commission
recommendations, which we presented. They were graciously
received. Except where the agency was deeply committed--and
there was general agreement, I would say, certainly from the
incoming surgeon general, Surgeon General Carmona. There was
agreement, basic agreement from the CDC with many of the
issues.
Only in those agencies where there was already a major
commitment to act--for example, interestingly, the VA and the
Department of Defense, those were the places where things
really happened. And other agencies, there was no clout. There
was no power. There was no ability to make--to really call
those agencies to account.
So that even though the Department of Education had the
wellness act for a wellness mandate from every State, it is
just not happening. Even though there is a National Center for
Complementary and Alternative Medicine at NIH, precious little
of the funding goes to wellness.
I think it needs a higher position. It needs more energy
behind it, to use a term that is perhaps appropriate here. It
needs a kind of constant watchdog. That is a different function
from either the surgeon general or the CDC.
Senator Mikulski. Dr. Jonas, did you want to comment? And
then Bob.
Dr. Jonas. Yes, I would agree with that. When we were first
writing this Wellness Initiative for the Nation, we had a small
group called the SWAT team, the Systems Wellness Advancement
Team. It was made up of----
Senator Mikulski. Yes, you can tell you are a military guy.
Dr. Jonas. We had a lot of fun with----
[Laughter.]
Senator Mikulski. We can have operations and all of these--
--
Dr. Jonas. These were senior health policy folks, ma'am,
who looked at this. We also then had a community discussion and
put out the first ideas. One of the first ideas was putting
this within a health reform office.
As Dr. Baase indicated, the focus quickly then got on
healthcare reform, some of the same things you mentioned at the
beginning, and did not address the issues that were required in
health. This caused us to change those recommendations from
community recommendations to look at something that really
could address issues across agencies, which are going to be
necessary if we are going to truly produce a culture and an
industry that promotes wellness.
Senator Mikulski. Bob.
Mr. Duggan. I noticed the surgeon general is a surgeon, and
CDC is about disease. I noticed, I think we are talking about a
massive cultural change, and that requires language change. I
noticed the other day--I don't know if he has been confirmed--
the new Secretary of Agriculture, Secretary Vilsack. He spoke
about food and his own growing up and his own issues with
obesity. It was in the Baltimore papers.
I thought isn't it interesting? He is speaking as if he
were ``secretary of wellness'' because he was talking about--
and this is a culture change. I think in order to take the
movement that has been happening across the country at a
grassroots level around this, it needs a language shift to be
put forward by the Congress and by the White House so that it
has a place to belong rather than in opposition to problems in
the healthcare system.
I believe our healthcare system will actually function well
when we take most of these wellness issues and return them to
the communities.
Senator Mikulski. Did any of our resource people want to
comment?
Dr. Berman. Could we give Dr. Berman a microphone there?
Thank you.
Dr. Berman. It is Brian Berman, professor of family
medicine, University of Maryland.
I think we have these different agencies. They do exist. It
is possible that the job could be done, but we need a
fundamental shift in our thinking, like I think all the panel
has been emphasizing. It really can't be business as usual.
A number of examples of that. We have now this stimulatory
package, and there is $8.5 billion that has gone to the NIH.
Well-deserved, well-needed. Just 1.5 percent of money that is
spent on research goes for health services research getting
clinical studies into practice.
We have a lot of the evidence that is there. The Cochrane
collaboration that has been around for quite a while--now we
have in our database 25,000 randomized control trials in the
database of complementary medicine, over 700 systematic
reviews. There is a lot of evidence there, but it needs to get
into clinical practice.
With that type of research, at 1.5 percent of the overall
research dollars, there has to be a re-dressing of that
imbalance.
Senator Mikulski. Thank you.
Let the record show that those words were spoken by Dr.
Brian Berman of the University of Maryland.
Let me summarize what I think the point that you all have
made, which is, sure, we need a surgeon general. And yes, we
need the agency for the--oh, wait a minute. That is the Senate
bell. It is not an air raid drill. You don't have to go under
the desk.
[Laughter.]
It is the pause that refreshes. That as we fashion--first
of all, this is a historical moment. Second, we have
presidential leadership that says we have got to make
healthcare available to more Americans and we have got to do it
in a way that achieves health outcome goals and also is
affordable and sustainable.
We have got to get it right the first time. This can't be
kind of trial and error that we might do demonstration
projects. And in that process, as that is being developed,
there needs to be a place at the White House with the
President's healthcare czar that focuses on, no matter what we
do, that prevention and wellness are part of that. They are not
viewed as one more silo, that it is integrated throughout the
entire system.
That prevention is not a new silo, and prevention is not
synonymous with one more test, though I think we would all
agree mammograms have a role. Evaluation for diabetes and those
with genetic propensity, testing is important. That wellness is
not a silo, and prevention is not a silo.
It has got to be integrated, and that person has to be
right at the table working on what is going to be not a reform
effort, but a transformational effort that involves both
providers, clinicians, the people who are going to pay for it,
etc. Is that it?
Once that is done, the surgeon general might be one of the
main implementers. Yes, we do need to refresh and reinvigorate
our Centers for Disease Control, but they are not the ones that
are going to do the policy. They will be the implementers. This
office needs to be at the table at this moment in history, just
like the healthcare czar might eventually go away and then be
integrated.
Integrative health has to be integrated in the system, but
you need somebody in charge always being this voice at the
table. Does that kind of summarize it in a nutshell?
Dr. Gordon. Absolutely.
Senator Mikulski. Now let me go to the concept of
integrative healthcare because the way it might be heard here
at this hearing is that it is being synonymous with
complementary medicine or even alternative medicine. Is that
the case, or is that just one of the tools of integrative
health?
Who would like to answer that question? Dr. Gordon and then
Dr. Kreitzer, if you want to jump in?
Dr. Gordon. Sure, I will be happy to start. I think that
there is a point that self-care is the true primary care, and
it is the integrative care. It is the care of the whole person
in which the whole person is completely involved and to which
he or she is committed. That is the basis.
Self-care includes what we eat, how we exercise, how we
deal with stress, our relationships with other people, our
environment, where we work, where we go to school. That has to
be absolutely fundamental in this transformation.
Once that happens and once we work on our consciousness and
we become aware of the consequences of what we do for ourselves
for good or ill, once we become aware of how our mind works and
how our thoughts work and where we get in our own way and where
we cause problems for other people, at that point, we are
clear-headed enough--whether we are clinicians in practice or
we are kids in school--to begin to make much wiser choices. We
are much less burdened by old worn-out ideas.
Senator Mikulski. I want to come back to self-care.
Dr. Kreitzer, do you want to comment on that?
Dr. Kreitzer. I agree with Dr. Gordon that self-care is
certainly a cornerstone.
Senator Mikulski. Now remember the question that I asked.
He is talking about self-care. Maybe self-care is integrative
care. I asked the question, because this is the hearing on
integrative healthcare. The Institute of Medicine is having one
on integrative medicine, the way--and again, I will go to the
way Senator Harkin and I saw this, which is integrative
healthcare is even broader than integrative medicine, which
goes to the office that you all wanted.
Dr. Kreitzer. Yes. For the last 3 years, I actually served
as the vice chair of the Consortium of Academic Health Centers
for Integrative Medicine, a group of 42 medical schools that
have programs in integrative medicine. They would define,
Senator Mikulski, that that is relationship based. It is
holistic care. That it includes working with all therapeutic
approaches, including complementary and alternative medicine.
I think many of us prefer the term ``integrative health''
because we feel like that is broader than the discipline of
medicine that reflects a narrower perspective. But certainly,
as I look at what the pillars----
Senator Mikulski. Is it synonymous with alternative and
complementary medicine, or is it different?
Dr. Kreitzer. It is broader. It includes complementary and
alternative medicine, a broad array of therapeutic approaches
that include those practitioners as well as some of those
therapies. It also includes conventional care.
Talking about integrative health is blending the best of
healing practices and traditions. I just have to say that I
think labels can be very powerful, but that they can be
misleading. For many years, we called this whole field
``alternative,'' and then we began to use the word
``complementary.'' Now often the term is used ``integrative.''
I think those labels, to some extent, have lost a lot of
meaning. People, consumers are interested in healthcare that
works, and they want to be able to access the best of healing
traditions. They don't really care so much what the label is.
Senator Mikulski. Bob, hold up a minute. I want to go back
to Dr. Gordon.
First of all, let me tell you what I think you just said
because it goes to the silo thinking. If we start with where
you all began in your testimony, No. 1, that what we have now
is an insurance-based--whether the insurance is public
insurance or private insurance, it is an insurance-based,
disease-focused, silo functional.
For everything, you go to one doctor. You get one set of
tests. You go to another doctor, etc. And that it is very silo
thinking. In fact, the system is not--we don't demand of the
healthcare system what we demand now of our new health
technology.
We demand of our new health information technology that it
be interoperable, and what integrative healthcare is, is that
it is interoperable, and all aspects are focused on the
patient, and every aspect is working for the positive outcome
because the person is not a test. If you say, well, who is
Barbara Mikulski? You say, a 4 foot 11--and then we could take
the other data from there--person.
[Laughter.]
You had my blood work, my cholesterol test, my mammogram,
etc. That is not Barbara Mikulski. Those are aspects that need
to go into me being able to be a vigorous, functioning Senator.
But there is a lot more to it.
Isn't that it, Dr. Kreitzer?
Dr. Kreitzer. Yes.
Senator Mikulski. Right. Well, can I come back now, though,
to self-care? Because this will be another naysayer question,
and I would like to clarify it.
Well, it is great to talk about self-care, but self-care
doesn't cure diabetes. What do you do if you have got lung
cancer, where does self-care come in? Don't you need drugs?
Don't you need doctors? You know, what is the self-care? It
sounds a little woo-woo, like if you drink ginger juice, you
won't need bifocals anymore.
Dr. Gordon. It is a great question. In fact, self-care can
cure most diabetes. That is the answer. That changing your
diet, changing your patterns of exercise, dealing with stress
better will take care of most Type 2 diabetes, which is the
predominant form of diabetes.
What I am saying is self-care is central because it is
integrative. Integer means whole. We are working with whole
people. Self-care is part of treating lung cancer.
A very interesting study was done years ago on people with
lung cancer. What they found is that those people who felt they
were doing better, who had a more positive attitude, who were
more engaged with their care not only felt better, but they
lived longer than those people with absolutely the same
diagnoses and stage of disease who felt more pessimistic and
didn't take care of themselves.
Self-care is part of all care. If you learn how to relax
and do some breathing exercises before you have surgery, you
will need less anesthesia. You will have fewer complications.
You will get out of the recovery room faster. You will get out
of the hospital faster. And you will need fewer drugs.
Self-care is primary. All the other care, of course, it is
necessary in many situations, but we have totally reversed it.
We go to the pills right away. Somebody comes in with a little
bit of diabetes. They are put on drugs right away, and nobody
is really working with them on diet, on exercise, on dealing
with stress.
We have got everything upside down and inside out, and we
have to come back to basics. Hippocrates said in extreme
situations, extreme remedies. When necessary, you use the drugs
and surgery. You don't rush to them right away. It doesn't
work, and it makes us sicker in the long run.
Senator Mikulski. Bob, and then Dr. Jonas.
Mr. Duggan. As someone outside of the system, basically not
coming from the medical model, I am very aware that the labels
CAM and alternative and integrated were put onto us to put us
in a silo to relate to the other silos.
I am thinking of what you are saying about diabetes and how
it can be managed by an individual. That individual with
diabetes usually has three or four other symptoms going on,
whether they are pathologies or not. Yet they will be sent to
one practitioner for this, or one technique for this, and they
are divided up.
Whereas, a patient is the only one who knows how the five
or six sets of symptoms go together. It is only talked about as
integrated medicine from the perspective of techniques because
of history.
I am remembering when I had pneumonia when I was 5 or 6,
long before we went to doctors, everybody in the neighborhood
knew how to tend me through pneumonia. It was part of the
wisdom of the neighborhood. Gradually, as I have gotten older,
my body has been carved up into different specialties--to go to
a headache doctor or go to an acupuncturist or go to someone.
My body was not broken up that way when I was a young
person. I can remember back to a time when the wisdom lived in
the community, and all of the symptoms my body put out were
part of my integrating how I stayed well. It is the history of
CAM or alternative, integrated is a way to attempt to silo
something that in the living patient is not separable.
Senator Mikulski. Well, I am going to come back then
because we are going to go to Minnesota and the so-called
healthcare home. I want to hear about it from the workplace
because there is already consensus building within the Congress
that as we do our legislation, we are going to be focusing on
either having a medical home or a health home, and how do we
then follow the patient through?
We have had extensive hearings already based on other IOM
work and so on.
Dr. Baase. I wanted to respond to the self-care question
for a moment. I think self-care exists. It is not a matter of
us saying we have it or we don't have it or we want it or we
don't. It is going to be there, no matter whether we decide or
not because it is just a fundamental reality. It is whether or
not we acknowledge it and help it to be more successful and
utilize it as part of the effectiveness of our whole system.
I mean, self-care happens, and unfortunately, we are not
acknowledging it all the time that people have this role and
they make decisions. Even in the current sort of illness
system, people make decisions every day. They decide when to
access the healthcare system. They decide how they are going to
follow or agreements that they might have made or not and what
they are going to do for their own care.
Self-care happens at every stage of a person's life, and it
is happening in concert with the system. We just need to really
embrace it, acknowledge it, and improve it.
Senator Mikulski. Well, I am going to move on now to the
concept of a health home or a medical home right now. For the
earlier discussions in this committee, we have talked about a
medical home. I want to talk about the Minnesota effort and
then the Dow effort.
What we have talked about already was the idea that we
would move to universal coverage, regardless of what the model
is. People would be based in a medical home that would start
with primary care, get some type of assessment, and then they
would be followed through if they needed.
Usually they would trigger that because of some
presenting--or it could be just pediatrics. It could be
prenatal care. It could be a variety of things.
One of my questions was, well, who is going to be the case
manager? While I have heard about the nurses today, which I
value, I am going to put my social work hat on because I have a
master's degree in social work. Often what is left out of the
integrative healthcare debate is the role of social work.
Social work must be a part of this.
We believe you start with the individual. The individual
goes within a family in a community. If you don't recognize
that the individual is living within a family and community,
you are not recognizing reality, because they either help or
hinder what is going to happen.
If you live in a community with clean water, clean air, and
a low level of violence, you have a pretty good chance of
making it to the eighth grade. Many of our communities don't
have those odds with them, particularly in some of our urban
areas.
So let us go back. What we are talking about then is some
type of access that is followed through. Once again, my
question is: Who is going to be in charge of the follow-through
and how do they follow through?
My question is how does this work? Usually, whether you are
discharged from a hospital or your primary care doctor sees
you, the doctor gives you a prescription, and they will give
you a plan, and then they say you have to go on a diet and
exercise. Then you get one sheet of paper that tells you about
fruits and vegetables. Maybe you can afford to buy them. Maybe
you can afford not to buy them, etc., though the affluent tend
to be.
My question is what is this idea of a medical home? How
would we make sure that people really could comply or
participate in the program, and who is going to see that they
do it? And who is in charge of this thing called diet and
exercise that runs through every single program that comes up,
and particularly in the management of chronic illness?
I don't know if I was clear in my question.
Dr. Kreitzer. Well, I can tell you, Senator Mikulski, that
even the decision to call it a healthcare home rather than a
medical home reflected the desire to shift the focus from a
disease orientation, and there was an understanding that while
often we think of primary care as being provided by physicians,
that in addition to nurse practitioners, that there certainly
are pharmacists, there are social workers, there are physician
assistants. There are others who could be that first provider
point of contact, and those people are very appropriate to
provide that coordinating function that you are talking about.
I think the concept, very much, of a healthcare home is to
have primary care coordinated in a comprehensive and integrated
way. What you raised in your question about who is in charge of
this diet and exercise piece----
Senator Mikulski. Well, who is in charge?
Dr. Kreitzer. Right.
Senator Mikulski. Then, No. 2, the person in charge is
usually the primary care doctor. I don't know of any primary
doctor that is going to call you up and say, you know, ``Did
you eat your fruits and vegetables today, and what are some of
the issues to help you with the program?''
Dr. Kreitzer. Well, two things, Senator Mikulski. I would
say, for one, often it is better to have that first line of
care a nurse practitioner or somebody else who actually has the
time to spend with patients, who is actually really taught in
their education much more about how to work with patients, how
to activate patients, how to coach patients.
Why not in a healthcare system as a first line of defense,
so to speak, have practitioners that can really take time with
patients to do that? Physicians generally in a primary care
setting have 10 minutes or less to spend with patients. They
don't have the time to do that health education or even that
counseling over chronic disease.
It is a team effort.
Senator Mikulski. Tell us how it works.
Dr. Kreitzer. Well, the Minnesota healthcare home
legislation was just passed, and so they are just implementing
healthcare homes. The way that it will work is that in a
healthcare home, a nurse practitioner or a physician assistant
or a medical doctor will be the one responsible for providing
that care coordination. Many of the demonstration projects
there are actually teams.
While there might be a person in charge of coordinating, we
are seeing more and more use of health coaches. We are seeing
health coaches employed not only by managed care, by hospitals,
by industry, and health coaches are people that can really have
a health professional background. They are part of the team.
They can sit down with patients and really explore what are
the barriers to making changes in their life? What are the
goals that they want to achieve? And help them really develop a
plan. It is much more than just passing out a sheet of paper
and saying, ``Eat better and exercise.''
People really need help looking at their lives, and how are
they going to do it? How are they going to make those changes?
Senator Mikulski. Well, who is going to pay for that?
Dr. Kreitzer. Well, that is the issue that we are all
talking about today. Right now, people pay for a function like
health coaching out of pocket, and that is not generally
something that is reimbursed.
Senator Mikulski. Who is going to pay for it in Minnesota?
Dr. Kreitzer. In Minnesota, health coaches are paid for
out-of-pocket. Under the legislation that was passed, nurse
practitioners will be reimbursed when they serve as healthcare
home coordinator.
Senator Mikulski. That is one of the real factors that we
would need to think about. Whether you call it a health home or
a medical home, which is really the gateway.
Dr. Kreitzer. Right.
Senator Mikulski. And then the gateway to assessing where
people are, then they would follow through.
We heard of a great program in Howard County, MD, but
before we go to that, isn't this kind of what you did at Dow?
Could you tell us what you do, how this works at Dow?
The results that you gave were stunning in terms of it, and
how it also has an impact on shareholder value because Dow is
not in the business of being a demonstration project in
healthcare. It is a profit-making company.
Could you tell us what this is and what this health
assessment and health advocacy and case management and all is?
Dr. Baase. Well, we started this off with a mission to
improve the health of our people. In fact, we set ourselves
what we thought was an audacious goal to say that we would
improve the health of our people by at least 10 percent in 10
years as measured by health risk factors and prevalence of
conditions.
What we use as a health assessment process, every single
employee is invited in to participate voluntarily in the health
assessment process. At that, there is a comprehensive
assessment questionnaire and set of tests, and then there is an
individual health improvement planning session, which is done
with that individual as a counseling effort.
From there, they are referred and followed up to a whole
team of professionals. They can be referred to a dietician, an
exercise physiologist. They are not just given a sheet of paper
with a list of vegetables on it or something, there is a team
base. We also work very closely within the community with the
person's primary care provider, their family doctor or
whatever. So we coordinate in that care.
That is just for keeping people healthy. If people happen
to have an illness or a health challenge of some type, we have
this health advocacy coach model, and we use our nursing staff,
as well as all the rest of our staff, who work with that
individual. Again, it is voluntary. We contact them if they are
ill or out of work and say, ``Can we help you, provide
services?''
I want to reinforce a point that you made about social
workers and the community. We use our own staff for this
because they live in the community, and part of their
responsibility is to know all of the services and the
professionals in that community so that we can serve as an
advocate and coach with an individual to find their best path
to healing and health with them.
We use all the knowledge of the local community, and that
is the process that we use for both health assessment and
referral. In addition to that, there is a culture aspect. I
think you are familiar with the Guide to Clinical Preventive
Services probably. There is another guide called the Guide to
Community Preventive Services, which talks about population
health and what is the evidence base for improving the health
in large populations?
We use that to try to create, use peers and policies and
even workplace health advocates within natural workgroups to be
the spearhead. We do leader training to try to educate our
leaders how they can be better role models and advocates of
health and what they can do. That is a great service to improve
and expand the culture that really enables people to live in a
healthy way.
Senator Mikulski. That is fascinating. Is the Dow
healthcare for its employees a self-funded entity?
Dr. Baase. Yes, we are.
Senator Mikulski. So, you essentially are like your own
insurance company. Is that correct?
Dr. Baase. Yes. We actually pay all the bills.
Senator Mikulski. First of all, you are a global
corporation. You embody some of the things that Dr. Jonas said
about why prevention and wellness worked in the military;
because it is a corporate structure. In some ways, I don't mean
command and control in a negative sense, but you can establish
policies throughout the corporate community and have those
specific programs, specific resources, a model and a corporate
culture that both supports it and encourages it.
Would you say that was partially not only for availability,
but for a corporate culture that encourages both early
participation and ongoing participation? Am I getting that
right?
Dr. Baase. Yes. That is true. We focus on individuals and
individual counseling and support, small groups, as well as the
corporate culture. I think the culture is a very important
factor.
You mentioned and others have mentioned how the community
and the environment that people are in can have a big impact,
and one thing that became clear to us a while back was if we
are really trying to transform the health of this population,
instead of just saying, ``well, the culture has a big
influence,'' we need to become far more sophisticated in
understanding that aspect and how to intentionally harness
culture to be a positive force and make that a piece of the
whole strategy.
We have also done something extremely unique in that the
health professionals in our staff--our physicians, our nurses,
our dieticians, our exercise staff--all of our professionals
have their personal bonus pay tied to the success of our
population.
If our population gets healthier, then they are eligible
for that portion of their bonus. If the population health
status does not improve, then they would not get that. We
voluntarily said our purpose here is to support people in being
healthier, and we should measure and hold ourselves accountable
for that.
We do a great deal of measurement on our population, but we
also feel a great sense of accountability and, I will say, a
lot of personal passion in caring for the people. Based upon
that, the employees and their families really trust and
understand that we are there for their best interest.
Senator Mikulski. Well, this is pretty bold, and I am going
to also turn to Dr. Goetzel and his views on a business model
here. Then we will come to the community model in Howard
County.
First of all, could you tell me what the health assessment
is?
Dr. Baase. Sure. It is a health history questionnaire,
which covers all the same things you would typically see--
family history, personal history, your health habits. It has
within it the typical health risk assessment questions about
your behaviors, and then we also do biometrics--height, weight,
blood pressure, lipid profile.
Senator Mikulski. But you are not the primary care? In
other words, Dow is not running an HMO?
Dr. Baase. No.
Senator Mikulski. An in-house HMO?
Dr. Baase. No.
Senator Mikulski. The Dow employees have their own primary
care physician and their own network of specialists. Is that
correct?
Dr. Baase. Yes. That is correct.
Senator Mikulski. Yet inside the corporation, inside the
corporate doors, there is this assessment. Are you, you meaning
Dow, in touch also with the primary care?
Dr. Baase. Yes.
Senator Mikulski. So you have their medical history? You
have their traditional medical program, as we would know it?
Dr. Baase. Our employees are in a traditional PPO model for
their healthcare. We have an onsite occupational health clinic
operating as well. Within those clinics, we provide these other
assessment services and additional clinical care.
We coordinate, though, that care with their primary care
physicians. We are very clear about the fact that we are not
the primary care physician. We give people copies of their
tests, suggest they share those with their provider----
Senator Mikulski. Well, let me give you an example, and it
is something that I also did at Howard County. Let us say that
you have an employee, and he has been a faithful employee. All
of a sudden he is beginning to develop rates of absenteeism. He
has gained about 50 pounds. He comes in to talk to maybe one of
your health assessors.
We find out that he has just gotten divorced. His blood
pressure is coming off the roof, and he feels his life is
falling apart. He is crazy about being in Dow because he has
got a job and he feels he has some security and a base being
there.
What would happen to somebody like him there?
Dr. Baase. Well, it would be a consultation with one of our
health staff. He would be offered the Employee Assistance
Program services for counseling, sounds like some distress, and
would look at the medical history and would ask him what is
going on with their primary care provider or other physicians
and how we could coordinate and provide support.
We would make sure that they were aware of all the services
that were available to them through their benefit plan and
other company services, and what is available in the community.
Then, depending on how that individual wanted to see things
happen, we may, with their permission, coordinate more directly
with their primary care.
We would ask for a release of information to have a
personal discussion with their physician to see how we could
all work together and bring our resources and the communication
with that provider or any other providers together. We would
work with the individual.
Senator Mikulski. How would you stick with him? Where would
the advocacy and case management come in? What you are
describing here?
Dr. Baase. Yes. That is----
Senator Mikulski. You would just stick with him. Then he
would say, ``Look, you know, I can only do what I can do. I am
going to take my pills.'' OK? That is not a bad thing if you
have high blood pressure.
Yet on the job, as you say, there are leaders. There are
supervisors, and they still know ongoing stress, etc. Would you
then--and we understand freedom of choice and all that. You
would stick with him then through counseling and offer it? Is
this where the culture comes in, to say, ``Joe, we are with
you. This might not be the right time, but this is where we
are.''
Dr. Baase. Absolutely.
Senator Mikulski. And repeatedly maybe reach out in an
appropriate way?
Dr. Baase. Yes. I mean, we don't believe that health is
something you edict or mandate to people, but they actually
sort of move through their own processes, and we help to
facilitate that and to partner with people as best we can. We
don't set rules about what they must do or must not do.
Senator Mikulski. Well, I have given you an extreme
example, but what you are saying is they have their physicians.
This is what is coming up also in the whole idea of a medical
home, and I am kind of doing this more like a conversation, and
I know the hearing is taking a little bit longer.
What you are saying is you have your physicians, and you
have your traditional framework. Along with this, in order to
make and maximize, there needs to be this involvement and this
case management for other resources. Some would be healthcare,
and it might be, ``Look, why don't you get into our exercise
program, or how about the company bowling league?''
Now that is exercise, and it is companionship. Maybe that
is what he needs right at that particular moment, to get out
with some other people, work off some of that stress, or maybe
it is a martial arts program or something that the guys are
into. Is that the kind of thing you are talking about?
Dr. Baase. Yes, absolutely. We would try to understand with
that person's life what is going to work best with them.
Senator Mikulski. Yes. Sister? Did you have your hand up?
Sister Kerr. Thank you. I wanted to relate to that and also
go back to your silo question that I have been thinking about.
What I wanted to say in this particular case, one of the
things I think we are asking about, as we move from the
individual to family to community, etc., part of the new
thinking may be that, for example, Cathy's program or all of
us, we may have new forms of education that we use in the
media.
It could be programs that we put into the schools, you
know, that is not just for Dow. I have always said if we
exercised before the nightly news, we would change America's
morbidity in 6 months, or teaching Qigong on the schools. Dr.
Oz has done more than the surgeon general that I know of on
Oprah.
There are a lot of things that we haven't--Emeril is on the
Green Channel now on television talking about organic foods and
how to cook them. We haven't gotten quite creative yet, I
think, on what all we could do.
Going back to the silo conflict, and I am not sure I have
enough time or clarity to say this. I think we are still caught
in a moment, and everybody is sort of sick of this word
``paradigm.'' We are about a paradigm shift on every level.
Mary Jo mentioned that we have so many similar problems in
healthcare as Wall Street. We have come out of the model of
opposition and competition, and part of that is reflected in
healthcare with specialists and that we don't really believe
things are interrelated. The new paradigm is saying we must
focus on relationship and cooperation.
I think things like why FDA hadn't talked to CDC and the
surgeons didn't talk to the dietary department, it is because
we don't believe that old song, you know, ``The head bone is
connected to the neck bone,'' and all that stuff.
This patriarchal model and this inability to know how to
relate is because we really are doing something new. We haven't
had the committee in healthcare that said we have got to have
the people from agriculture come. We have got to have the moms
come. We need to see why the poor children who are hyper, we
have got to find out about the lifestyle and do they--just had
a patient this week. They just stopped red dye number 20, and
behavior changed like that.
I am trying to just say that it is new what we are trying
to do, and we are not practiced at it yet. We don't really
believe everybody should be talking together, or we say it is
impossible. It is because we haven't practiced is my belief.
It is a part of the change of an ecological model, like
when I taught children in ecology in Italy, as a matter of
fact. They were so on to clearing the streams of debris and bad
water, but they had no connection that they were 80 percent
water. And so, maybe all Coca-Cola didn't make sense to put
into your body.
We--and I am pointing to me. We haven't quite got it yet
how to do it. That is why we are here today. It is exciting,
and we are going to figure it out.
Senator Mikulski. Well, but you see, that is exactly what
we are looking at. One, this Dow model is really very
interesting. The Minnesota approach--I don't want to call it
the Minnesota model. There is the famous Minnesota model that
has been so wonderful in terms of addictions and compulsive
behavior, but this Minnesota approach.
Then this hearing--this committee conducted a hearing in
Howard County, MD, in which a very dynamic county executive and
a bold health commissioner said that they were going to insure
the uninsured and did a big step forward. When we held our
hearing, we found out, No. 1, that at least 10 to 15 percent of
the people who came were eligible for other programs, and they
could be connected. And then there were other initiatives.
What was so amazing was not only that Howard County moved
to cover people, which is the traditional word being used here
now in the insurance debate, but then they saw the person or
the family all the way through and continue to see them. Be
involved with them either through physicians, nurses, or health
coaches to ensure that they were able to participate in those
things that were most helpful to them.
We also listened to some of the people who benefited from
the program, and they talked about what it meant to have
somebody feel that the system was on their side, that they were
part of a system and that in that system that everybody was on
their side and that they had a point of contact that stuck with
them repeatedly to either give them new information, new
direction, or help them find a way to get back--while they were
being followed and also what we would regard as traditional
medical approaches.
These people had very serious medical problems. They had
doctors. They had specialists. They had pharmaceutical
interventions, even some surgical. The most important thing
that they felt, in addition to medical care as we know it, was
that someone was on their side, and there were other things
from the neurological person problem that had physical therapy
and exercise.
Mr. Duggan was an active participant and has been a
spokesperson on this whole idea of a health coach, which you
have talked about, which is an out-of-pocket expense, which
automatically rules out a lot of people.
Dow provides health coaching. They have maybe another name
for it, but that is because they are not the doctor. They are
the coach and the advocate. Essentially, what Dow says to its
employees, ``We are on your side. Whatever you have got going
on in your life, if you have some challenges, we are here to
help you.''
Have I summarized the Dow culture in terms of this?
Bob.
Mr. Duggan. As you know, I was sitting in the audience at
that hearing you held in Howard County, and I was so struck by
the two women, both of whom, as you said, had severe, severe
social, medical problems. Their comment was that suddenly when
they came into the program, they were being held by a culture.
They spoke more about the way they were greeted, the way people
tended them, the sense of support.
One of them said, ``I felt like I won the lottery because I
finally found a whole network of support.'' Those were very
touching words, and I am struck--you are talking about cultural
shift. This is a massive cultural shift that Dr. Beilenson and
County Executive Ulman are doing there.
We have 50 years of telling people to go to an expert, and
I was struck when you mentioned social work. The dangerous
moment is at the first moment when somebody brings a problem to
the system. If they meet an acupuncturist, they are going to
get acupuncture. If they meet a surgeon, they are probably
going to get surgery. If they meet a social worker, they are
going to be listening to another story.
This first moment is the critical moment, and are they
being held with a trust that they are going to be partnered in
their own healing and somebody is really going to be with them?
When you talk about diabetes, it is who is going to go and walk
with them? Who is going to go and follow them through?
I want to say about health coaches, I hear what you are
talking about. It is very different with a health coach that
will tell you, ``You should do this.'' It is very different.
Senator Mikulski. You mean a school-marmish prompter or, in
other words, the health coach is not a compliance officer?
Mr. Duggan. That is right. That is right. They are a
relationship who evokes what you know about your healing and
makes available the supports of a broad community, from
surgeons to physicians to massage to yoga to tai chi, and can
guide you in what best serves you.
That is the development of this broad cultural shift. Right
now, the first point of contact is somebody who is medically
oriented.
Senator Mikulski. Well, Bob, share with us what the health
coach does in Howard County because it is so specific and I
think points out exactly what you are saying.
Mr. Duggan. Well, Peter Beilenson--Dr. Beilenson, the
health commissioner--has invited us to train the coaches and
the nurses and the doctors so everybody is speaking in the same
way. I am going to use a very specific aspect of it because it
is complex.
Every person I have ever met and our students meet has five
or six or seven symptoms. The body is very wise. When you
listen to the whole range of symptoms, and I say to somebody,
``What do you know about those symptoms,'' people begin to say
to us, ``Oh, I know how I generate my headache. I know how I
generate my asthma.''
It will be questioning about what you know already about
all the symptoms. Yes, treating the pathology, but what we know
is if the person tends to learn about their symptoms they
invariably say to me--well, we have data, it is very
interesting data that from four different studies--Claire
Cassidy did a good bit of it years ago--you can get 91 percent
relief of symptoms, but not get patient satisfaction.
Patient satisfaction in the studies was geared to ``I now
understand how I generate my symptoms.'' Once they get that,
they then are able to more manage their diabetes, more manage
whatever disease factor they have. That is the building of a
culture, which says, ``I will listen to you.''
A major complaint in American healthcare is nobody listens.
First day of diagnosis class in every form of healing is the
patient knows what is going on. We have to get back to that
culture, which reinforces exactly what you are saying. In many
ways, a social worker is more trained to take in that whole
dimension than many of the rest of us.
I want to applaud what I hear happening at Dow because it
is built in. That is the other thing about what Peter Beilenson
is doing. He is gambling, as the health officer, that providing
wellness coaches who will enable a person to live well, that is
going to cut costs and transfer the return on investment for
healthcare expenditures in Howard County, much as you are doing
in a corporation where it will return 10 cents on a share 2
years from now.
Senator Mikulski. Well, thank you. Those were excellent
comments.
I want to now turn to our resource people because it is now
about 10 minutes before 4 p.m., and we are going to have to
draw the hearing to a close.
I know, Dr. Kemper, you come here with a great background
in pediatrics. You gave us a great paper, and I think you want
to talk about the concept of what you see as integrative
healthcare? Did you want to comment?
Dr. Kemper. Yes, thank you.
You asked earlier whether integrative healthcare was the
same as complementary medicine, and I think you have heard
clearly no. Integrative healthcare is really an integrated
system, as they have at Dow, that looks, first of all, at the
goals. The goal is health. What are the components that get
there, building from the ground up, starting with a healthy
environment?
If we destroy the planet, what we do about health insurance
will be irrelevant. We have to have a healthy environment. That
is a physical environment. We have to get mercury out of the
fish that we eat by cleaning up the coal industry. These things
are all interrelated, and an integrated healthcare system looks
at a healthy physical environment, a healthy social
environment.
It means that children, if we want children not to be obese
and not to have attention deficit disorder, we have to give
them access to sidewalks, bike paths, recess, and fruits and
vegetables, and stop marketing unhealthy fast foods to them and
let them go through drive-through restaurants where they are
filling up on things that they have seen advertised on TV,
which they watch for hours because it is safer than letting
them play outside in many neighborhoods.
An integrative healthcare system means healthy physical
environment, healthy social environment, healthy lifestyle
habits. Healthy habits in the context of a healthy habitat.
Those healthy habits, as everybody has mentioned, nutrition----
Senator Mikulski. Can you repeat that? It is healthy?
Dr. Kemper. Healthy habits.
Senator Mikulski. Children have to be in a healthy habitat.
Dr. Kemper. Healthy habitat.
Senator Mikulski. And then help them with healthy habits.
That is a lot to say, but very good.
Dr. Kemper. We have to have healthy habits in a healthy
habitat, yes. Those habits include nutrition and fitness and
sleep and also include stress management and emotional self-
management.
Also, as Dr. Gordon mentioned, caring for one another, our
social relationships, building a peaceful environment so that
we don't have the conflict that is ongoing, the crime, the
turning to less skillful ways to manage our stress. Things like
smoking tobacco, alcohol, drugs, ways that people are using in
unskillful, unhealthy ways to manage their stress.
If we give kids the tools they need to learn to manage
those emotions and manage those relationships, they will be
much better able to manage their own health. We have to give
them a healthy environment in which to do that and support for
their families. Social policies that promote breast feeding for
at least the first year of life.
Ways to make it easy for children to get their
immunizations from any licensed healthcare provider instead of
restricting it to a few. On top of that, a primary healthcare
home with good coaching, as you have heard about, and then also
it includes, of course, hospitals and doctors.
I think for too long, the care of the American public has
been topsy-turvy with the most resources going to the most
expensive kinds of care instead of the most resources going to
a healthy habitat and healthy habits.
Senator Mikulski. Well, that is an excellent, excellent
summary.
I wonder if we could elaborate on that, but I want to come
to Mr. Goetzel. You have written a lot about the business
models involved here, and we have heard about Dow. Could you
share with us how you would see really developing this along
legislative lines, and what would be the barriers of
participation for businesses?
Dr. Goetzel. Sure. I am an applied social psychologist, but
I work with a lot of economists. The research that we do and we
have been doing for the last 20 years has been focused on
corporate initiatives in approving health and well-being of
their employee populations and their dependents.
We have worked with Dr. Baase for many, many years, and we
are now involved in a 5-year research study that is funded by
the NIH that is looking at environmental and social supports
for obesity management at Dow.
What is interesting about the work we do is that we, of
course, focus on health and health improvement and reduction in
risk factors and improving behaviors. We are also focused on
the economics, looking at healthcare utilization and costs,
looking at absenteeism, and looking at on-the-job productivity.
My comment and contribution to this discussion today is
that when we are assessing any of these intervention programs,
we ought to be very concerned about the economics, the
financial impact, and the cost effectiveness of alternative
methods.
There is not enough comparative effectiveness research done
in real world settings, in particular in corporate settings, to
see what works, what doesn't, and where do you get the biggest
bang for the buck.
Senator Mikulski. Well, one of the things I am going to ask
Dr. Baase to have the people at Dow give us are what are the
current legal impediments? Are they in the tax code? In other
words, what exists now--by the way Government does business
that would be a deterrent or a hindrance for corporations to do
this type of health promotion thing?
Our Finance committee is doing a great job. We will come
back to the tax code, to do that. What you talked about is
workplaces offer an ideal setting for health promotion, and
that is also what Dr. Baase said. You have consulted with
companies that have names like Dow, Johnson & Johnson, Procter
& Gamble, General Electric. These are really big companies, and
they are global, but many are in a variety of our communities.
The fact that we could take a look at this would be
something. Do you see that as, we lack the will? Do we not have
the right legislative framework? Is it the lack of leadership?
What would be the obstacles that would stand in our way, where
we would want to incentivize the private sector at the
workplace to do some of this?
If we look at where people are--our children are in school
and that is a good place to begin, with children. People go to
work. That is a really good place to do that. Plus, you have a
sense of community. Most people commute long hours. How do they
get home and do exercise?
Dr. Goetzel. Yes, we know quite a bit. However, it is not
very well adopted and implemented at workplaces. Even though a
recent study done by the Office of Disease Prevention and
Health Promotion found that 90 percent of American businesses
say they have health promotion programs in place, but only 6.9
percent have the essential ingredients to have those programs
be successful.
They really have not been taught. They have not learned.
They have not applied the kind of learning that we have
accumulated, from working with Dow and General Electric and
Johnson & Johnson and some other companies. There really isn't
a kind of dissemination and application of that knowledge into
the workplace.
That is a wonderful opportunity, 150 million to 160 million
people go to work every day, and it is a microcosm of society.
You can harness the energy, the education, the communication
channels, the culture. All the things that Dow is doing, you
can do that in all workplaces across the United States.
Senator Mikulski. What about one of the biggest employers
called the Federal Government?
Dr. Goetzel. Exactly right. Shoemakers' sons and daughters
are not doing what they ought to be doing. They are not
adopting these health promotion practices.
Now there are some wonderful notable new exceptions to
that. King County in Seattle, WA, and they have done a
remarkable job in providing these programs for their employees.
Ron Sims, who was the county executive, is now moving to
Washington as a deputy director for housing and urban
development.
We have done studies showing that over time they have
improved the health risk profile of the population and reduced
costs in a significant way. That is one example. There are
other examples, but not enough, not as many as we would like to
see at the Federal, State, and local levels.
Senator Mikulski. We often think of Government as providing
services. As you know, the national governors are meeting in
Washington. They have had a variety of conversations with the
President. We don't think of like, say, State government as
employees. I know our governor, Governor O'Malley, would.
I think this is a topic we would like to pursue more
because, first of all, I think the Federal Government should be
the model employer. We should not have wage discrimination. We
should have equal opportunity to think that all people have
abilities, etc.
Also we are a major buyer of healthcare. So that the
Federal Employee Healthcare Program, from the standpoint of
traditional Western medicine, is pretty good. I am talking
about, say, the standard option program. Yet, if you would go
into many of the agencies, you would see what you see
everywhere--stress, obesity, people who have children with some
very serious challenges, even if we look at the ``A words''
like asthma and autism.
I think it is something that we should talk about with the
Federal Government, but also with the State government because,
as you turn to the private sector, the profit-making sector,
you need to be able to say, ``practice what you preach.'' This
could be a way, as we look at implementing healthcare and also
some of these demonstration projects would be another way to
go.
We would like to really be able to talk more about it. What
you see are the incentives and the disincentives to do that.
I want to turn now to Dr. Berman, who, in addition to his
outstanding work in research, his home is the University of
Maryland. It is an academic center, and it has a variety of
schools from medicine, nursing, pharmacy, dentistry, and the
School of Social Work.
Dr. Berman, I wonder what you and Susan Berman could share
with us, your experience in trying to move the--what has been
your experience with the University of Maryland, and is that
even a good question?
Dr. Berman. It is an excellent question. It helped a lot
when you came that day to the VA hospital, and the president of
the university saw the support.
Senator Mikulski. We are coming back.
Dr. Berman. Good. We have seen the change since we came
there in 1991 until now. It has been a sea change, just like
this whole field, that has occurred. It has been a little
microcosm of that, and now it is completely an integrative
approach into many of the clinical departments and the basic
departments, so much so that it is in both the acute care side
as well as the chronic side.
An example of that is we have been working with the shock
trauma center for several years and have treated over 1,000
people in the trauma center, which, as you know, is one of the
largest trauma centers in the country and in the world. They
came to us because we had been working together as colleagues
for so many years and were sort of accepted.
They said we have a problem that a subset of our patients
with trauma there have a hyper-inflammatory state. If we can't
do something with our methods, they are the ones who go into
septic shock and die, and what do you have to offer?
We just began to work together. There was a little bit of
skepticism, I would say, from some of the people downtown. And
just gradually, they saw some difference, first with the
acupuncture with pain and inflammation and differences in
traumatic brain injury and began to work on some projects
earlier on to treat within the first 24 hours, or living lab.
The biggest shift that I have seen is when the nurses
there--we were teaching some mind-body courses in the School of
Social Work. Some of the nurses from shock trauma took this
training program and then brought it back and then, through a
series of efforts, started to bring it into the bedside.
The stories that have come out of there have shifted
everybody's thinking in the trauma center, right from Tom
Scalea, the head of the trauma center, all the way through to
the patient level. Because, in a way, it really is empowering
people right at the bedside.
Just one example of that is when a 19-year-old soldier came
back from the war, and he had lost all of his limbs. He was in
the trauma center. He really had, he said, no reason to live,
and there he was. One of the nurses that we had taught Reiki
and sound and visualization mind-body therapies began to work
with him a little bit.
Within a few days, he came back and said to the group,
``Thank you for giving me a reason for living.'' He went from
there from strength to strength, and I was just told the other
day that he had some artificial limbs, and he went skiing last
week.
There are similar stories like this that are emerging that
the university is seeing. They are seeing the impact, and so it
is spreading through the oncology and the heart center there,
that they are very much involved. It is not a big deal. It is
part of the standard care.
That is also, of course, supported by some of the evidence
and the research that we are working on together, both from
clinical trials and basic science.
Senator Mikulski. Well, that is a powerful story, and I
know each and every one at this table also could give very
powerful stories.
One of the hearings that we are going to have is going to
be lessons learned from the military and from the VA. We think
they have a lot to teach us in terms of their experience from
what this committee has already looked at; like health
information technology; a techno tool for case management; to
these interventions; particularly in integrative medicine that
have dealt with mind-body healing where the trauma is so
serious.
We are not the VA Committee. We don't--we are not stepping
on anyone's toes, but we have a lot to learn from them. And the
severity of illness and also for our military who served in
Iraq and Afghanistan, some have the permanent wounds of war
like you have described. As Dr. Gordon, who has worked in Gaza
and other war-torn places, and Dr. Jonas and all of you, people
will carry the permanent impact of war.
There is a lot to learn from what we are doing in
intervening, and so we are going to be holding a special
hearing just on that.
Then we will be holding another hearing on women, who often
pay more for health insurance, and the topic of the hearing
will be women who are overcharged, overmedicated, and
underserved. It is meant to be a very provocative hearing.
This hearing has been provocative in its own way because I
think it has provoked a lot of thinking. I think when we look
back on the history of the healthcare debate in the year 2009,
when we were really willing to do something about it, this
hearing is going to be one of the benchmark hearings as we laid
out these concepts about what needs to be done.
I think we are all very clear that integrative healthcare
is the way to go. It is individualized and patient focused. It
looks at the person within the workplace and in the family and
within the community. In providing and improving the health
outcomes for people, you can't have silos.
Also healthcare is not a linear system. It is not seeing a
primary care doc, being referred to the right test, to get the
right prescription, and so on. That is part of it, and we don't
minimize that, and we need to do that. That might or might not
help people get well and stay well, and then there are all the
other things that go into it. Those other things that go into
it also deal with those things that you must take personal
responsibility for, particularly diet and exercise.
In taking personal responsibility, you can't feel that you
are in it by yourself. You have to feel that there is help and
someone on your side, whether it is an individual coach,
whether it is the resources that the private sector or the
employer offers. And there are those things that you can take
ownership for yourself, that you have been taught to reduce
stress, and also for children as well, which I think is great.
We talked about children.
Diet and exercise are things that are involved in stress
reduction. That, in and of itself, would deal with two big
things--stress reduction and the management of chronic illness.
Because most chronic illness is diabetes, cardiovascular, high
blood pressure, those are the big three in our country.
There is also recidivism if someone has had an acute care
episode. If you come into a hospital for either a heart attack,
blood sugar hitting 300 or 400, or a fall that requires
orthopedic intervention, at the end, you come out and there are
all kinds of follow-up.
One of the big areas of healthcare cost is the lack of
follow-through when someone leaves a hospital and they come
right back and sometimes they return with not only the same
problems, but pretty significant infections.
I think we have learned a lot. I think I have learned the
principles. I don't think I am doing too bad as a social
worker, and so I think we have learned a lot. What we have also
seen is that there are examples going on. We want to learn,
know more about Minnesota. We want to learn more about the
Howard County model and the involvement of Tai Sophia.
A corporation like Dow Chemical has been involved. The
University of Maryland that pioneered, really, trauma medicine
in this country with Dr. Cowley is doing even more advanced
work looking at it. From our business model to also our
pediatricians who were here.
I think we have a lot to show for the record, and
Washington is going to be a very exciting place not only for
what our President is doing, but I think this hearing, the IOM
summit, and then the hearing that Senator Harkin and I will
have on Thursday will be very good.
We look forward to ongoing conversations with you, and we
are going to try to integrate your work into our work.
Thank you, and the committee is adjourned until next
Thursday.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement of Herbert Benson, M.D., Director Emeritus, Benson-
Henry Institute for Mind Body Medicine, Massachusetts General Hospital,
Mind Body Medical Institute Associate Professor of Medicine, Harvard
Medical School; and Gregory L. Fricchione, M.D., Director, Benson-Henry
Institute for Mind Body Medicine, Massachusetts General Hospital,
Associate Professor of Psychiatry, Harvard Medical School
Stress is pervasive and widespread. The prevention and treatment of
the harmful effects of stress on health and well-being to all ages is
vital and an important feature of the integrative components of
healthcare reform.
Over 60 percent of visits to healthcare providers in the United
States are related to stress and its manifestations.\1\ It has a
profound adverse influence on physical and mental health, on
performance and efficiency in the workplace, and on education of our
young people.
There are currently no effective pharmaceutical treatments or
procedural and surgical approaches that can counteract these harmful
effects. This testimony will provide the evidence for the necessity of
Health Care Reform to include scientifically proven and patient
acceptable approaches to alleviate the deleterious affects of stress.
STRESS AND THE FIGHT OR FLIGHT RESPONSE
Nearly 100 years ago, Walter B. Cannon described the ``fight or
flight'' response to stress, identifying a consistent set of
physiologic changes that occur when animals, including humans, are
exposed to stress.\2\ \3\ The characterization of this response was
revised and expanded on 40 years later by the physiologist Hans Selye,
who termed this response the ``general adaptation response'' to
stress.\4\ Several decades later, Sterling and McEwin proposed that
``allostasis'' is necessary to adapt to stress.\5\
Any situation that requires behavioral adjustment is stressful, and
the fight or flight response is evoked. Situations that are stressful
include worries about; health and well-being; family; financial
considerations; and terror situations. We characteristically do not run
or fight, yet secrete into our blood streams epinephrine and
norepinephrine. This response is not utilized to run or to fight and
causes or exacerbates a number of conditions that include coronary
artery disease, headaches, insomnia, incontinence, chronic low back
pain, disease and treatment-related symptoms of cancer, and improving
postsurgical outcomes, hypertension and arthritis.\6\
THE RELAXATION RESPONSE
Over 40 years ago an opposite mind body state, also consisting of
coordinated and reproducible physiological changes, was characterized
by Herbert Benson.\7\ \8\ \9\ Defined as the ``relaxation response,''
\9\ this state is identified by decreases in oxygen consumption,\8\
\10\ \11\ \12\ respiratory rate, and blood pressure.\7\ There is
reduced responsivity to norepinephrine \13\ \14\ \15\ and on fMRI
activation of specific brain areas \14\ as well as increased cortical
thickness.\15\
To the extent that any disorder is caused or exacerbated by stress,
the relaxation response has proven to be a successful intervention. Its
elicitation has been successful in disorders that include:
headache,\16\ \17\ \18\ decreased alcohol intake,\19\ decreased blood
pressure in hypertensive patients,\20\ \21\ \22\ \23\ \24\ \25\ \26\
\27\ premature ventricular contractions,\28\ anxiety,\29\ \30\ cardiac
surgery,\31\ femoral arteriography,\32\ premenstrual symptoms,\33\
infertility,\34\ \35\ \36\ and insomnia.\37\ \38\
MIND BODY EFFECTS AND INTEGRATIVE HEALTH
Since the time of Rene Descartes over 2 hundred years ago, the mind
has been considered separate from the body in Western civilization.
``It's all in your head'' became pejorative representing diseases that
do not have bodily manifestations.
The relaxation response with its above noted physiologic,
biochemical, and neurological changes is a mind body effect. It is
normally elicited through the repetition of a word, sound, prayer, or
phrase and everyday thoughts are disregarded when they come to mind.\9\
Hence the mind affects the body.
A recent 2008 publication \39\ describes how gene expression is
induced by the relaxation response. It provides conclusive evidence
supporting the mind body connection. It also reports the first evidence
that the relaxation response elicits specific gene expression changes
in both short-term and long-term practitioners. Techniques used to
evoke the relaxation response included several types of meditation,
yoga, Tai Chi, repetitive prayer, guided imagery, and Qi Gong.
Specifically, there are anti-oxidation effects as well as anti-
inflammatory changes. Hence, the mind is not separate from the body.
This recognition is an essential feature of integrative health.
THE MIND BODY-RESILIENCY PROGRAMS OF THE BENSON-HENRY INSTITUTE AT
MASSACHUSETTS GENERAL HOSPITAL
The clinical programs developed at the Benson-Henry Institute are
directed at the integration of the relaxation response with cognitive
restructuring, with positive psychology, with a patient's existing
beliefs and expectations (remembered wellness),\40\ and with exercise
regimens and appropriate dietary changes.
The programs include treatments for many conditions and are
entitled, the ``Resiliency Programs of the Benson-Henry Institute''.
Disease conditions include:
Autoimmune disorders,
Symptoms of cancer,
Chronic pain,
Gastrointestinal disorders,
Headache,
Heart disease,
Hypertension,
Infertility,
Insomnia,
Menopause,
Stress reduction,
Weight management, and
Any stress-related medical condition.
The Institute also has wellness programs for mothers that offer
solutions for managing the stresses of parenthood. It also offers
relaxation response training and yoga for well hospital employees.
For more than 35 years, the approaches of the Benson-Henry have
improved the lives of thousands of people whose conditions were caused
or made worse by stress. It also has trained many thousands of
healthcare professionals in its therapeutic and wellness programs under
the aegis of Harvard Medical School's Department of Continuing
Education and continues to do so.
MIND BODY INTEGRATIVE HEALTH IN THE WORKPLACE
As noted in the 2005 Harvard Business Review article \41\:
Managers apply pressure to themselves and their teams in the
belief that it will make them more productive. After all,
stress is an intrinsic part of work and a critical element of
achievement; without a certain amount of it, we would never
perform at all.
Yet the dangers of burnout are real. Studies cited by the
National Institute for Occupational Safety and Health (NIOSH)
indicate that some 40 percent of all workers today feel
overworked, pressured, and squeezed to the point of anxiety,
depression, and disease. And the problem is getting worse,
thanks to intensified competition, rapid market changes, and an
unending stream of terrible news about natural disasters,
terrorism, and the state of the economy. The cost to employers
is appalling: Corporate health insurance premiums in the United
States shot up by 11.2 percent in 2004--quadruple the rate of
inflation--according to survey figures from the Henry J. Kaiser
Family Foundation. Today, the American Institute of Stress
reports, roughly 60 percent of doctor visits stem from stress-
related complaints and illnesses: In total, American businesses
lose $300 billion annually to lowered productivity,
absenteeism, health-care, and related costs stemming from
stress.
The above Harvard Business Review article was published in 2005.
The business environment today in 2009 is notably more stressful! Mind
body integrative health approaches should be given even more
consideration. Their integration could have important disease
prevention manifestations.
The Benson-Henry Institute has trained individuals in many
different corporations to apply its anti-stress wellness programs to
healthy individuals. Its programs are easily replicable and can be
disseminated widely.
MIND BODY INTEGRATIVE HEALTH IN EDUCATION
Stress is pervasive in our educational system resulting in
absenteeism, poor academic performance, alcohol and drug abuse,
depression, and suicide. The stress management programs of the Benson-
Henry Institute Education Initiative were developed to address these
needs.
The Education Initiative program of the Benson-Henry Institute has
been in existence for several decades. It is a two-phase ``train the
trainer'' model. In phase one, the Educational Initiative provides
school staff with mind body skills for their own use. The second phase
demonstrates ways to bring these interventions directly to students.
In 1994, its stress management programs were applied to a high
school population in Lake Placid, NY. Exposure to this curriculum
resulted in significant increases in self-esteem and a tendency toward
``greater locus of control scores.'' \42\
In 2000, the Institute's mind body education curriculum was studied
in middle school students living in South Central Los Angeles, CA.
Teachers were trained in how to teach relaxation response exercises and
self-care strategies. Four measures of academic outcomes were analyzed.
Students who had more than two exposures to semester-long classes in
which teachers had been trained in the curriculum had higher grade
point averages, work habits scores and cooperation scores than students
who had two or fewer exposures. Students who had more exposures to the
curriculum demonstrated an improvement in academic scores over the
course of a 2-year period.\43\
In 2002, the Institute investigated the results of six 90-minute
group training sessions at Harvard University. A 6-week mind body
intervention yielded significant reductions in psychological distress,
state anxiety, and perceived stress.\44\
A recently completed, unpublished controlled investigation in a
suburban Boston high school found that high school students partaking
in the Institute's curriculum had significant improvements in perceived
stress, state anxiety, trait anxiety, and stress management behaviors.
The Educational Initiative is easily replicable and has been
disseminated throughout the United States.
CONCLUSION
As noted above, over 60 percent of visits to health care
professionals are related to stress, and stress also has profound
adverse effects in the work-place as well as in schools.
There are no current effective pharmaceutical or procedural and
surgical treatments in the current medical system to counter-act the
harmful effects of stress. Stress management programs developed at the
Benson-Henry Institute have been addressing the needs of patients with
stress-related disease. They are well-received, carry few risks, and
are easily replicable in most health care settings. They're also easily
adaptable to a wellness model as evidenced by the Institute's workplace
and educational programs.
Healthcare reform should integrate scientifically proven mind body
stress management programs. To do so, it may be necessary to utilize
White House and Congressional level approaches rather than simply
attempting to modify the extant disease-treatment based system.
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15. Lazar, S.W., et al. Meditation Experience is Associated With
Increased Cortical Thickness. Neuroreport 16, 1893-1897 (2005).
16. Benson, H., Malvea, B.P. & Graham, J.R. Physiologic Correlates
of Meditation and Their Clinical Effects in Headache: An Ongoing
Investigation. Headache 13, 23-24 (1973).
17. Benson, H., Klemchuk, H.P. & Graham, J.R. The Usefulness of the
Relaxation Response in the Therapy of Headache. Headache 14, 49-52
(1974).
18. Fentress, D.W., Masek, B.J., Mehegan, J.E. & Benson, H.
Biofeedback and Relaxation-Response Training in the Treatment of
Pediatric Migraine. Dev Med Child Neurol 28, 139-146 (1986).
19. Benson, H. Decreased alcohol intake associated with the
practice of meditation: a retrospective investigation. Ann NY Acad Sci
233, 174-177 (1974).
20. Benson, H., Rosner, B.A., Marzetta, B.R. & Klemchuk, H.M.
Decreased Blood-Pressure in Pharmacologically Treated Hypertensive
Patients Who Regularly Elicited the Relaxation Response. Lancet 1, 289-
291 (1974).
21. Benson, H., Rosner, B.A., Marzetta, B.R. & Klemchuk, H.P.
Decreased Blood Pressure in Borderline Hypertensive Subjects Who
Practiced Meditation. J Chronic Dis 27, 163-169 (1974).
22. Stuart, E.M., et al. Nonpharmacologic Treatment of
Hypertension: A Multiple-Risk-Factor Approach. J Cardiovasc Nurs 1, 1-
14 (1987).
23. Dusek, J.A., et al. Stress Management Versus Lifestyle
Modification on Systolic Hypertension and Medication Elimination: A
Randomized Trial. J Altern Complement Med 14, 129-138 (2008).
24. Benson, H., Marzetta, B. & Rosner, B. Decreased Blood Pressure
Associated With the Regular Elicitation of the Relaxation Response: A
Study of Hypertensive Subjects. In Contemporary Problems in Cardiology.
Stress and the Heart (ed. E. RS) (Futura, Mt Kisco, 1974).
25. Lehmann, J.W. & Benson, H. Nonpharmacologic Treatment of
Hypertension: A Review. Gen Hosp Psychiatry 4, 27-32 (1982).
26. Lehmann, J. & H, B. The Behavioral Treatment of Hypertension.
In Hypertension: Physiopathology and Treatment (ed. K.O. Genest J,
Hamet P, Cantin M) 1238-1245 (McGraw-Hill, New York, 1983).
27. Friedman, R., Stuart, E. & Benson, H. Essential Hypertension:
Nonpharmacologic Adjuncts to Therapy. In Current Management of
Hypertensive and Vascular Diseases (ed. F.E. Cooke JP) 1-7 (Mosby-Year
Book, St Louis, 1992).
28. Benson, H., Alexander, S. & Feldman, C.L. Decreased Premature
Ventricular Contractions Through use of the Relaxation Response in
Patients With Stable Ischaemic Heart-Disease. Lancet 2, 380-382 (1975).
29. Nakao, M., et al. Anxiety Is a Good Indicator for Somatic
Symptom Reduction Through Behavioral Medicine Intervention in a Mind/
Body Medicine Clinic. Psychother Psychosom 70, 50-57 (2001).
30. Benson, H. The Relaxation Response and the Treatment of
Anxiety. In The American Psychiatric Association Annual Review 8 and 1
(American Psychiatric Press, Washington, 1984).
31. Leserman, J., Stuart, E.M., Mamish, M.E. & Benson, H. The
Efficacy of the Relaxation Response in Preparing for Cardiac Surgery.
Behav Med 15, 111-117 (1989).
32. Mandle, C.L., et al. Relaxation Response in Femoral
Angiography. Radiology 174, 737-739 (1990).
33. Goodale, I.L., Domar, A.D. & Benson, H. Alleviation of
Premenstrual Syndrome Symptoms With the Relaxation Response. Obstet
Gynecol 75, 649-655 (1990).
34. Domar, A.D., Seibel, M.M. & Benson, H. The Mind/Body Program
for Infertility: A New Behavioral Treatment Approach for Women With
Infertility. Fertil Steril 53, 246-249 (1990).
35. Domar, A.D., Zuttermeister, P.C., Seibel, M. & Benson, H.
Psychological Improvement in Infertile Women After Behavioral
Treatment: A Replication. Fertil Steril 58, 144-147 (1992).
36. Domar, A. & H, B. Application of Behavioral Medicine Techniques
to the Treatment of Infertility. In Technology and Infertility:
Clinical, Psychological, Legal and Ethical Aspects (ed. K.A. Seibel MM,
Bernstein J, Levin SR) 355-360 (Springer-Verlaq, New York, 1993).
37. Jacobs, G.D., et al. Multifactor Behavioral Treatment of
Chronic Sleep-Onset Insomnia Using Stimulus Control and the Relaxation
Response. A Preliminary Study. Behav Modif 17, 498-509 (1993).
38. Jacobs, G.D., Benson, H. & Friedman, R. Perceived Benefits in a
Behavioral-Medicine Insomnia Program: A Clinical Report. Am J Med 100,
212-216 (1996).
39. Dusek, J.A., et al. Genomic Counter-Stress Changes Induced By
the Relaxation Response. PLoS ONE 3, e2576 (2008).
40. Benson, H. & Friedman, R. Harnessing the Power of the Placebo
Effect and Renaming It ``Remembered Wellness''. Annu Rev Med 47, 193-
199 (1996).
41. Benson, H. Are You Working Too Hard? A Conversation With Mind/
Body Researcher Herbert Benson. Harv Bus Rev 83, 53-58, 165 (2005).
42. Benson H, K.A., Kornhaber C, LeChanu MN, Zuttermeister PC,
Myers P, Friedman R. Increases in Positive Psychological
Characteristics With a New Relaxation-Response Curriculum in High
School Students. The Journal of Research and Development in Education
27, 5 (1994).
43. Benson, H., et al. Academic Performance Among Middle School
Students After Exposure to a Relaxation Response Curriculum. The
Journal of Research and Development in Education 33, 9 (2000).
44. Deckro, G.R., et al. The Evaluation of a Mind/Body Intervention
to Reduce Psychological Distress and Perceived Stress in College
Students. J Am Coll Health 50, 281-287 (2002).
Prepared Statement of Brian M. Berman, M.D., Professor of Family and
Community Medicine, Director, The Center for Integrative Medicine,
University of Maryland School of Medicine and Susan Hartnoll Berman,
Executive Director, The Institute for Integrative Health
I would like to thank Senator Mikulski and the members of the
Committee on Health, Education, Labor, and Pensions for this
opportunity to submit testimony on the role of integrative health in
health care reform. My name is Brian Berman, I am a professor of family
and community medicine at the University of Maryland School of Medicine
and the director and founder of the University of Maryland Center for
Integrative Medicine. The Center is a National Institutes of Health
Center of Excellence for Research in integrative medicine and has been
evaluating the scientific foundation of complementary therapies and an
integrative approach to patient care for the past 18 years. I am chair
of the Cochrane Collaboration's Complementary Medicine Field whose work
involves collecting and systematically reviewing the worldwide
scientific literature in complementary medicine.
I also would like to thank Senator Mikulski and the members of the
Committee on Health, Education, Labor, and Pensions for this
opportunity to submit testimony on the role of integrative health in
health care reform. My name is Susan Hartnoll Berman. I am the
executive director of the Institute for Integrative Health, a non-
profit organization that fosters interdisciplinary collaboration and
innovative thinking that will catalyze new ideas in healthcare.
The United States spends more on health care than any other
developed country and yet we rank near the bottom on most standard
measures of health status. Chronic diseases, which account for 75
percent of health care expenditures, are precipitated by modifiable
risk factors, yet a mere 3 percent of our health care resources are
dedicated to prevention and health promotion. At the same time,
services with no measurable benefit consume 30 percent of Medicare
dollars and many high tech tests are paid for without proof of
efficacy. Clearly, maintaining the status quo risks further
catastrophic financial strain on our country and its citizens and will
do little to improve the health of our Nation.
An integrative approach to health care holds potential for reducing
costs, improving treatment and prevention of disease, and refocusing on
health promotion. The core principles of this approach include:
Maximizing the ability of individuals to take
responsibility for their own health;
Focusing on patient-centered, whole person care;
Strengthening the healing partnership between health care
providers and patients;
Emphasizing prevention and health promotion;
Embracing the connection between mind, body and spirit;
and
Making use of all appropriate, evidence-based therapeutic
approaches.
There are a number of specific strategies inherent in an
integrative approach that I believe could be transformative for
bringing better health to all Americans.
IMPROVE CONSUMER ACCESS TO HEALTH INFORMATION
Health information technology, including electronic health records
and interactive, web technology, can play a key role in enabling
consumers to manage their own health information, become educated, and
communicate with practitioners beyond the clinic-based encounter. We
need electronic health records that have the functionality to capture
all clinical encounters, including those with complementary
practitioners, in order to overcome fragmentation, facilitate
coordination of care and services (including preventive service
reminders) and reduce errors. Judicious and secure use of the web would
allow people to interface with their medical records and health care
team, link to good information, identify local resources, and connect
to social networks and counseling for help with weight loss, smoking
cessation and wellness promotion activities. With the explicit
development of consumer-friendly summaries of research findings by
organizations such as the Cochrane Collaboration, high quality
information can inform personal as well as professional decisionmaking
on all health care options. Currently, there are over 600 systematic
reviews on integrative medicine in the Cochrane database of systematic
reviews. Efforts to conduct more reviews and consumer summaries are on-
going and need to be accelerated in order to get the information to the
public.
SUPPORT BETTER REIMBURSEMENT FOR PRIMARY CARE AND PREVENTION, COVERING
A BROADER RANGE OF HEALTH CARE PRACTITIONERS AND HEALTH CARE MODALITIES
Primary care plays a vital role in promoting healthier lifestyles
and identifying conditions early enough to limit severe health
consequences. Within our current system, reimbursement rates for time-
intensive primary care visits are significantly lower than those for
specialty care visits. This has negative ramifications for both health
and costs. Primary care physicians, such as family medicine doctors,
have less time to get to know their patients or spend time on education
and, with poorer reimbursement and increased time spent on paperwork,
there has been a marked decline in the number of doctors going into
primary care. This has resulted in a shortage nationwide, with a lack
of care in many communities as well as over-reliance on specialists. We
are also largely ignoring a valuable pool of health professionals who
can provide primary care at lower costs. Removing insurance barriers to
coverage of non-physician health providers would boost primary and
preventive care. These providers include nurse practitioners,
physician's assistants and health coaches or navigators as well as
various complementary care providers including naturopathic physicians,
who tend to focus on wellness.
We need to increase the public's access to complementary medicine
therapies where there is evidence to support them. There is a growing
body of scientific literature on complementary therapies (the Cochrane
database now has over 23,500 complementary medicine clinical trials),
and yet most people, including vulnerable populations such as the
elderly, must pay out-of-pocket for services like acupuncture. Clinical
trials and systematic reviews point to the safety and effectiveness of
acupuncture for chronic pain conditions such as osteoarthritis and low
back pain, and studies at our Center at the University of Maryland show
cost savings and improvement in quality of life. Likewise, mind/body
approaches, such as mindfulness meditation and yoga, are being shown to
reduce chronic stress and related disorders, and enhance resilience.
Through proactive use of these approaches we could substantially
decrease the incidence of prevalent health disorders such as heart
disease and diabetes which are some of the biggest burdens to our
society. If Medicare increases primary care coverage and reimburses for
acupuncture, mind/body therapies and other complementary medicine
modalities, it will help push private insurers to do the same. For this
to happen, an important step is to introduce a coding solution like the
ABC codes into the HCPCS coding system. The existing coding does not
adequately represent the services delivered by the vast majority of
licensed health care practitioners (2.7 million nurses, 150,000 nurse
practitioners and all of the complementary medicine providers)
therefore accurate actuarial data cannot be generated to sort out what
works from what does not. ABC codes have been successfully piloted in
several of the State Medicaid programs and demonstrated real cost
savings, but they have still not been adopted.
INVEST IN RESEARCH THAT HAS DIRECT IMPACT ON TRANSLATING KNOWLEDGE INTO
PREVENTION, DIAGNOSIS AND TREATMENT OF DISEASE
Recent infusion of substantial funding into the National Institutes
of Health as part of the American Recovery and Reinvestment Act of 2009
is much needed and should be dispersed with a mind to how we can
improve the quality of our health care system. Currently, the
predominant focus of NIH is on basic science research. While there is a
strong emphasis on translational research, this typically refers to the
``bench to bedside'' enterprise of harnessing basic science research to
produce new drugs, devices and treatment options for patients. However,
there is a second type of translational research that the Institute of
Medicine's Clinical Research Roundtable describes as ``the translation
of results from clinical studies into everyday clinical practice.''
This enterprise is of particular interest to health services
researchers and more directly addresses issues raised in the IOM's 2001
Crossing the Quality Chasm report by focusing on improving access to
care, reorganizing and coordinating systems of care, helping clinicians
and patients to change behaviors and make more informed choices, and
strengthening the patient-clinician relationship. Both translational
research approaches are vital, but health services research represents
only 1.5 percent of biomedical research funding and yet for many
diseases it could save more lives. If we redress this imbalance we will
also focus more directly on behaviors that are conducive of health and
well-being.
In addition, we need to increase funding for practice-based
research networks and studies in clinical as well as community settings
to test practical strategies to improve the quality of preventive and
chronic illness care. We also need to fund research of multi-modality
approaches to complex chronic problems, like lower back pain for
example, where single therapeutic approaches have had minimal effect
and a combination of modalities such as exercise, acupuncture, mind/
body approaches, and anti-inflammatory medications may need to be used
at the same time. Collaboration between our Center and the University
of Maryland Shock Trauma Center also suggests combining modalities such
as mind/body therapies and acupuncture with standard care may be useful
in acute conditions, such as trauma, particularly for reducing pain and
inflammation. We also need comparative effectiveness studies that
involve head-to-head trials between interventions and this should
include complementary therapies. For example, studies of osteoarthritis
of the knee show the effect size of acupuncture to be equal to the
effect size of many of the standard arthritis pharmaceuticals, but with
a much improved safety profile.
TRANSFORM HEALTH CARE AT THE FRONT LINE
Health is influenced by factors in five areas--environment,
behavior, genetics, social circumstances and health care. To have a
truly effective health care system we must, therefore, involve all
stakeholders in our communities at all stages of the life spectrum.
There are some exemplary wellness initiatives being pursued along these
lines in the State of Maryland that I would like to draw attention to
in closing. One of these is at the Lockheed Martin corporation which is
responsible for half a million lives and the other is the Howard County
Health Department's Healthy Howard Initiative. Both have instigated a
comprehensive ``citizen-centered'' (rather than ``patient-centered''),
community-based integrative approach that promotes health and wellness
for their constituents. Key elements of both these initiatives include
encouraging healthy communities (e.g., cafeterias and restaurants with
no trans fats, no smoking policies, emphasis on exercise in the
workplace or schools), health plans for all their constituents (in
Howard County this includes those who are uninsured) with an emphasis
on wellness promotion, incentives for individuals, such as lower
deductibles if they engage in healthy behaviors (e.g. attending yoga
classes or weight loss programs), and incentives for health
professionals to engage in early intervention, preventive activities.
We now need health care policies that will in turn provide incentives
to businesses, communities and counties nationwide to adopt similar
programs.
Substantial improvement in the health of all Americans can be
achieved if we have the courage to reset our health care compass. Our
health care system needs to shift from a predominant emphasis on
disease management to one of prevention and, ultimately, promotion of
optimal health across the lifespan. This won't be an easy task, but
answering President Obama's call for a new era of responsibility, we
should seize the opportunity and pursue the potential of integrative
health. Thank you.
Prepared Statement of Gary Deng, M.D., Ph.D., Wendy Weber, N.D., Ph.D.,
M.P.H., Amit Sood, M.D., M.Sc., and Kathi Kemper, M.D., M.P.H.*
Integrative Medicine Research: Context And Priorities
Abstract.--Integrative medicine research is important for the
understanding of and effective, timely implementation of this new
paradigm of health care. Integrative medicine is prospective and
holistic, while patient-centered and personalized at the same time,
focusing on health and well-being in addition to disease management.
The scope of research thus extends beyond evaluation of specific
therapies, including complementary and alternative medicine modalities,
for safety and effectiveness in treating specific diseases. Integrative
medicine research also includes evaluation of multi-modality whole
system intervention, practitioner-patient relationship and partnership,
patient goals and priorities in his sense of well-being, promotion of
patient self-care and resilience, personalization of diagnostic and
therapeutic measures to individual patients and the environmental/
societal consequence of health care. In this paper, we describe the
state of science of integrative medicine research, research needs, and
the opportunities offered by cutting edge research tools. We will
propose a framework for setting priorities in integrative medicine
research, list areas for discussion, and pose a few questions on future
research agenda.
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* The responsibility for the content of this paper rests with the
authors and does not necessarily represent the views or endorsement of
the Institute of Medicine or its committees and convening bodies. The
paper is one of several commissioned by the Institute of Medicine as
background for the Summit on Integrative Medicine and the Health of the
Public. Reflective of the varied range of issues and interpretations
related to integrative medicine, the papers developed represent a broad
range of perspectives.
---------------------------------------------------------------------------
INTRODUCTION
Integrative medicine refers to a new paradigm of health care that
is prospective and holistic, while patient-centered and personalized at
the same time, focusing on health and well-being, in addition to
disease management. The scope of research within integrative medicine
as discussed in this paper is not only the evaluation of specific
Complementary and Alternative Medicine (CAM) therapies for safety and
effectiveness in treating specific medical problems (the Institute of
Medicine published its report Complementary and Alternative Medicine in
the United States in 2005). Integrative medicine research also includes
multidisciplinary whole systems interventions; clinician-patient
interactions; patient goals and priorities; the value of meaning;
patient self-care; environmental factors and social policies affecting
health quality; and system factors affecting availability of resources
that promote health, health behaviors, or health care. Research must
also address patient-centered care in the context of family, culture,
and community. The research agenda for integrative medicine is by
nature broad and comprehensive, rather than being focused solely on the
effects and mechanism of selected therapies.
There is a lack of a critical mass of research evidence about
integrative medicine and the effect of this approach on health care;
this lack hampers understanding and effective, timely implementation.
One challenge for research even in the limited realm of therapeutic
effectiveness concerns the definition of ``effectiveness.'' Is it
simply a change of a physiological parameter like blood pressure or
survival time? Or an improved overall sense of well-being? Or can there
simultaneously be multiple definitions, multiple goals? Who should
define them--policymakers, clinicians, patients, or families? Another
challenge is that interventions in integrative medicine are often
multi-faceted with complex unknown interactions among the components.
Therapies delivered as a multi-factorial ``system'' rather than a
simple treatment regimen present challenges to design studies that are
rigorous yet provide results that are meaningful in real-life clinical
practice. Similarly, while traditional biomedical research focuses on
one particular disease outcome, integrative care often addresses
multiple health concerns within a single individual; new research
models may need to be developed to address the challenges inherent in
many simultaneous treatments for multiple health concerns. For example,
inclusion of all patient-important outcomes in consideration to create
the best evidence has been incorporated in the Grades of Recommendation
Assessment, Development and Evaluation Working Group (Guyatt et al.
2008).
These challenges offer a fertile ground for the development of
innovations to advance science. In this paper, we describe the state of
science of integrative medicine research, research needs, and the
opportunities offered by cutting edge research tools. We will propose a
framework for setting priorities in integrative medicine research, list
areas for discussion, and pose a few questions on the future research
agenda.
Context: State of the Science, Research Needs, and Integration With
Cutting Edge Research Tools
RESEARCH METHODOLOGY
Study Design
Integrative medicine researchers have broadly adopted the paradigm
of evidence-based medicine (EBM)--the randomized controlled trial
(RCT). There is no disagreement that the RCT method helps reduce
multiple sources of bias. Although RCTs are often viewed as the gold
standard, it is not possible to conduct RCTs for each research question
we have, due to logistic, economic, or ethical concerns. RCTs do not
include patients who do not fit rigorous entry criteria (such as those
unwilling to be randomized), which limits generalizability. RCTs also
only provide population or group estimates of likely outcomes rather
than assurances of individual outcomes with treatment. While the
strongest conclusions and inferences can be reached when there is
concordance between research using different methods (e.g., RCT and
prospective cohort methods), such concordance is not always found, such
as the different conclusions reached by cohort versus RCT studies of
hormone replacement therapy (Chlebowski et al. 2003; Wassertheil-
Smoller et al. 2003), antioxidant supplements to prevent cancer (Bardia
et al. 2008) or decreased risk of dementia/cancer in patients using
statins (Shepherd et al. 2002). Observational studies have provided
important insights such as the role of smoking, radiation, hormone
levels, and high meat diets in the development of different kinds of
cancer, lipids and coronary disease, hypertension and stroke, and
sleeping position and sudden infant death syndrome (Rothwell and
Bhatia, 2007). Researchers need to recognize that different kinds of
research serve complementary functions in developing balanced and
mature evidence (Avorn, 2007).
Outcome Assessment Tools
Optimal health in integrative medicine refers to a state of well-
being of the whole person--physical, mental, social, and spiritual
(Gaudet and Snyderman, 2002; Maizes and Caspi, 1999; Singer et al.
2005; Snyderman and Weil, 2002). With this multi-dimensional definition
of health in mind, outcome measurements in integrative medicine
research would need to expand beyond reduction of a specific symptom or
reversal of a specific disease process (Bell et al. 2002; Long, 2002).
Integrative medicine researchers can make use of outcome
measurement methods developed in other disciplines of medicine,
especially those emphasizing functional performance in addition to
structural integrity and those taking into consideration the
psychological and societal impact of disease (Coons et al. 2000), such
as rheumatology (Ward, 2004), neurology (Miller and Kinkel, 2008; von
Steinbuechel et al. 2005), geriatrics (Burns et al. 2000; Demers et al.
2000), rehabilitation (Andresen and Meyers, 2000; Donnelly and
Carswell, 2002), and pain and palliative care (Turk et al. 2002). They
form a foundation from which integrative medicine researchers can build
a truly global outcome measurement system.
Another important aspect in outcome measurement is the role of the
patient. In patient-centered care, what patients perceive is equally,
or perhaps more, important than what physiological parameters tell us.
Integral to this process is incorporating individual patient
preferences in considering appropriate study outcomes (Guyatt et al.
2000). Information about patient preferences can be obtained from
decision analyses, cost-effectiveness analyses, studies of social
values, one-on-one interviews, focus groups, and interviews of citizen
juries and other novel sources (Ryan et al. 2001). The value of
patient-reported outcome measures is increasingly being recognized by
the medical community (Clauser et al. 2007; Lipscomb et al. 2007).
Integrative medicine researchers can incorporate what was learned into
their own studies and develop new methods tailored to their own
practice models (Hull et al. 2006; Sagar, 2008; Verhoef et al. 2006a).
Application of Information Technology
The impact of information technology (IT) on integrative medicine
is enormous. Easy and instant access to a vast amount of health-related
information on the Internet via search engines such as Google and Wikis
plays a large role in patients' senses of empowerment. This
decentralization of information makes practitioners not the sole source
of information. Meanwhile the information, not uncommonly inaccurate,
false, or contradictory, overwhelms, confuses, and frustrates patients.
On the other hand, information technology provides researchers with
numerous tools which have not been utilized adequately.
IT can be used to enhance research in its capacity as a
communication tool in many ways.
1. E-mails improve communications between providers and patients
(Mandl et al. 1998; Roeder and Martin, 2000). Would e-mail
communications encourage a patient's stake in self-care, facilitate
timely management of emerging medical problems, or reduce unnecessary
utilization of health care resources? Would e-mail communications help
monitor patient responses and adverse events, improve patient
compliance, and refine patient-centered outcome evaluation in clinical
studies? These are interesting research questions.
2. Online support groups, bulletin boards, chat rooms, blogs, and
social network sites are frequented by patients to exchange notes on
their diseases and health care providers. These media, by their nature,
are part of the social context of a patient health care experience.
They can be used to learn patients' perspectives of the medical
problems. Participation of providers in those discussions, medicolegal
issues notwithstanding, could promote provider-patient partnership.
They also serve a venue to reach a large number of patients eligible
for research studies.
3. The raw computing power available to researchers has made
certain previously impossible research feasible now. This is most
obvious in bioinformatics and personalized medicine. IT enables the
processing of the astronomical amount of information generated from
genomic studies and establishing links between genomic variations and
clinical outcomes.
4. Image processing technologies can be used to standardize and
quantify some of the diagnostic techniques in traditional medicine. For
example, image digitalization and analysis of the appearance of the
tongue and complexion in Traditional Chinese Medicine would help
eliminate evaluator biases (Dong et al. 2008; Pang et al. 2004; Zhang
et al. 2005).
5. Web 2.0 technology (Giustini, 2006) provides a social,
collective, and collaborative platform that simplifies data creation,
integration, sharing, and reuse. It fosters collective intelligence to
create and discover new knowledge (Zhang et al. 2008b). When expanded
beyond the research community, it also presents a platform in education
to other health care providers and the public (Bender et al. 2008;
Eysenbach, 2008).
6. Finally, artificial intelligence has potentials in contributing
to whole-system research (Patel et al. 2008; Ramesh et al. 2004). Many
traditional medical systems rely on pattern recognition for diagnosis.
For example, diagnoses in Ayurvedic medicine or Traditional Chinese
Medicine are established by a constellation of findings during patient
interviews and physical examinations that are seemingly unrelated when
viewed through the eyes of Western medicine. However, recognition of
those patterns may represent empirical knowledge on clinical
manifestations of some yet nondelineated pathophysiological links
(Zhang et al. 2008a).
EPIDEMIOLOGICAL STUDIES
The large numbers of epidemiological studies in integrative
medicine have been on the use of CAM (Barnes et al. 2004; Eisenberg et
al. 1998; Eisenberg et al. 1993; Ritchie et al. 2005; Wilson et al.
2006; Yussman et al. 2004). Several population-based surveys have
included a CAM component including: the 1999 and 2002 National Health
Interview Survey; 1994 Robert Wood Johnson Foundation National Access
to Care Survey; 2001 Michigan State Behavioral Risk Factor Surveillance
System; 1997 National Health Expenditures Survey; 2001-2003 National
Comorbidity Survey Replication; and 1996 Medical Expenditure Panel
Survey (Ni et al. 2002; Paramore, 1997; Rafferty et al. 2002; Ritchie
et al. 2005; Wang et al. 2005). Much of what we know about CAM
utilization comes from these surveys, and continued collection of this
data is essential to further understanding of the field. Research
describing integrative medicine programs including how they were
established, the services offered, and the training and research
projects they are conducting are emerging (Boon and Kachan, 2008; Deng,
2008; Katz et al. 2003).
It would be beneficial to the field if a standardized survey could
be created to gather data about CAM and integrative medicine use. This
standardized survey could then be made publicly available to all
researchers conducting population-based surveys. This may be the most
efficient way to collect descriptive data about integrative medicine's
utilization, cost-effectiveness, and the characteristics and
satisfaction of the individuals who use it. Continuation of the CAM
supplement to the National Health Interview Survey (NHIS) is a minimal
requirement to maintain an understanding of the utilization of CAM in
the United States. Efforts should be made to review and update the
supplemental questions in the NHIS to be sure that they reflect changes
and trends in the field, such as including questions specifically about
integrative medicine and CAM treatments recommended by conventional
providers.
BASIC SCIENCE RESEARCH
Mechanistic Studies of Specific CAM Modalities
Mechanistic studies have begun to elucidate biomedical mechanisms
to explain clinical effects of CAM therapies. For biologically based
therapies such as botanicals, the research generally identifies the
(presumed) active constituent(s) of the study agents and the
physiological pathways through which those constituents affect physical
systems (Ribnicky et al. 2008). This approach is highlighted in the NIH
Botanical Research Centers Program, where researchers ``identify and
characterize botanicals, assess bioavailability and bioactivity,
explore mechanisms of action, conduct preclinical and clinical
evaluations, and help select botanicals to be tested in clinical
trials'' (Barnes et al. 2008b). Isolating active compounds and their
derivatives has led to the development of many pharmaceuticals
currently used in clinical practice, such as the taxanes and
camptothecins in cancer chemotherapy (Wall and Wani, 1995). However,
the complex composition of botanicals may contain multiple compounds
that synergize for a greater total activity than individual
constituents (Raskin et al. 2002; Rong et al. 2008; Schmidt et al.
2008; Ye et al. 2007). Studying natural products with complex
composition presents challenges, such as standardization and quality
control, unknown active constituents, multiple potential biological
targets, and complex interactions among the constituents (Khan, 2006;
Yeung et al. 2008). Newer experimental paradigms are needed to assess
the differential effects of complex mixtures versus simple compounds.
Similar to conventional pharmacotherapy, this research needs to also
take into account the effects of secondary metabolites of botanicals on
biological materials.
Mechanistic studies of energy medicine, manipulative practices, and
mind-body therapies involve delineation of the physiological pathways
modulated by them. For example, research in
``psychoendoneuroimmunology,'' focuses on an interdisciplinary study of
interactions among behaviors, the conscious mind, the utonomic nervous
system, hormones, and immune functions (Kiecolt-Glaser and Glaser,
1995; McEwen, 2007). Through such research, the relationships between
stress and disease, especially stress and immune function, are being
explored (Ehlert et al. 2001; Gaillard, 2001; Kiecolt-Glaser and
Glaser, 1992; McEwen, 2008; Miller and Cohen, 2001). The neuroendocrine
stress response and immune systems have a bidirectional relationship
that can affect susceptibility to inflammatory diseases. Individual
variability in neuroendocrine responsiveness may contribute towards the
efficacy of mind-body therapies (Marques-Deak et al. 2005).
The brain plays a central role as a target of stress and stress
therapy. Neuroplasticity, a dynamic process that constantly alters the
neurochemical, structural, and functional components of the nervous
system related to experience would be a worthwhile target to study with
mind-body interventions. Some of the examples of the effect of mind-
body approaches on brain structure include the increase in pre-frontal
cortex volume following cognitive behavioral therapies in patients with
chronic fatigue syndrome (de Lange et al. 2008) and increase in pre-
frontal cortex and right insula volume with meditation (Lazar et al.
2005). The role of neurotrophins, particularly Brain Derived
Neurotrophic Factor (BDNF) as a mediator for neuroplasticity is
beginning to emerge and needs to be further characterized with respect
to mind body intervention (Hennigan et al. 2007). The brain is a
malleable organ and the lack of resilience may be a key aspect of
anxiety and mood disorders, as well as other systemic problems.
Like psychotherapy, many behavioral and mind-body interventions
require active patient participation, which cannot be reproduced in
animal studies. Advances in functional neuroimaging technology such as
functional Magnetic Resonance Imaging (fMRI) or Positron Emission
Tomography (PET) can demonstrate changes in activity in regions of the
brain in real-time and enable us to study the complex neuronal matrix
involved in real-world emotional and social experience (Eisenberger et
al. 2007). The technology has been used to study mind-body therapies or
energy-medicine modalities in recent years (Lewith et al. 2006). For
example, anterior cingulate cortex and dorsolateral prefrontal areas
appear involved in meditation (Cahn and Polich, 2006). Activities in
the thalamus, insula, and cingulate cortex, areas involved in
processing of pain signals, are modulated by meditation (Kakigi et al.
2005; Orme-Johnson et al. 2006) and acupuncture (Cho et al. 2006; Dhond
et al. 2007). The specific neurobiologic changes that might mediate the
placebo effect could offer innovative therapeutic insights. A recent
example of this is the effect of placebo on endogenous opioid release
in core affective brain regions (Wager et al. 2007). The efficacy of
placebo effect on enhancing frontal modulation of nociceptive sensory
and/or affect processing and individual variability in placebo
responsiveness as a predictor of efficacy of mind-body interventions is
an interesting area for future exploration (Benedetti et al. 2005;
Oken, 2008).
Because physiological pathways are increasingly understood to be
nonlinear and multidimensional, traditional laboratory approaches tend
to be too simplistic to capture the complexity of real clinical
situations. Advanced mathematical and statistical modeling techniques
will be important to advance research in the complex systems of
integrative medicine. Sensitive and noninvasive methods that can
measure multiple biomarkers are likely to help identify pathways that
may be selectively affected by different interventions. A good example
of this strategy is the use of sweat patch method for measuring neural
and immune biomarkers in sweat (Cizza et al. 2008; Marques-Deak et al.
2006).
Application of Genomic Science To Personalized Health Care
Some technologies developed in genomic sciences can be harnessed to
enhance integrative medicine research, in particular towards
personalized health care. Genomics refers to the study of all the genes
of a cell, or tissue, at the DNA (genome), mRNA (transcriptome), or
protein (proteome) levels. It is well known that individuals respond
differently to risk exposure and interventions. More knowledge of the
DNA sequence of the human genome and the function of individual genes
and their variants makes it possible to identify individuals at risk
for a particular medical condition or responsive to a particular
intervention.
Variations at nearly 100 regions of the genome have been associated
with an increased risk for diseases with a complex genetic background,
such as diabetes, inflammatory bowel disease, cancer, and heart disease
(Chanock and Hunter, 2008). For example, single nucleotide
polymorphisms (SNPs) in a region of the long arm of chromosome 15 were
identified as strongly associated with lung cancer (Amos et al. 2008;
Hung et al. 2008; Thorgeirsson et al. 2008). This region contains
nicotinic acetylcholine receptor subunit genes. Genetic variants in
nicotinic receptor genes were found to be linked to nicotine dependence
and smoking behavior, which may explain why some patients are
particularly resistant to smoking cessation measures (Berrettini et al.
2008; Saccone et al. 2007).
Another example is how individuals respond differently to nutrients
(nutrigenomics) (Trujillo et al. 2006). Individuals with one genetic
variant of an intestinal fatty acid-binding protein gene have
significantly greater decreases in plasma total and low-density
lipoprotein (LDL)-cholesterol and apoB when consuming a diet rich in
soluble fiber (Hegele et al. 1997). Better understanding of
nutrigenomics would help us in understanding the ``individuality'' of
one's response to bioactive food components (Milner, 2008). The
Institute of Medicine has held a workshop to review the state of
nutritional genomics research and to provide guidance for further
development and translation of this knowledge into nutrition practice
and policy (Stover and Caudill, 2008).
The ever-expanding database in pharmacogenetics helps us understand
why individuals respond quite differently to the same biological
intervention. For instance, the best responses to erlotinib treatment
in patients with nonsmall-cell lung cancer are seen in those who have
mutations in epidermal growth-factor receptor, the target of erlotinib
(Rosell et al. 2006). Differences in response to drugs or dietary
supplements may also come from varied metabolism (Kadiev et al. 2008).
CYP2D6 is one of the major drug-metabolizing enzymes involved in
converting codeine to morphine. CYP2D6 gene is highly polymorphic, with
more than 100 allelic variants in the population. Depending on the
allele combinations, a patient can be a poor, intermediate, extensive,
or ultra-rapid metabolizer. Extensive metabolizers may have markedly
increased risk of side effects while poor metabolizers would experience
poor efficacy of the drug (Somogyi et al. 2007).
Epigenetics refers to the study of heritable changes in gene
function that occur without a change in the DNA sequence (Riddihough
and Pennisi, 2001). Such changes can occur via mechanisms such as DNA
methylation, chromatin structural modifications, and RNA interference
(Jenuwein and Allis, 2001; Okamura and Lai, 2008; Reik et al. 2001).
Inspired by the Human Genome Project, researchers are working to
provide high-resolution reference epigenome maps and speed progress in
epigenetic research (the Alliance for the Human Epigenome and Disease)
(Jones, 2008). Epigenetics takes into consideration the effects of the
environment on gene expression patterns that can be passed along to
daughter cells, setting the stage for disease preventive interventions
to have a lasting effect. For example, epigenetic alterations often are
involved in the earliest stages of tumor progression, and usually
precede genetic changes in the cell and tumor transformation (Toyota
and Issa, 2005). These findings may lead to novel cancer prevention
strategies early in the cancer pathogenesis process (Sawan et al.
2008), including use of botanical agents or nutritional approaches
(Kirk et al. 2008).
Although these technologies are exciting and promising, they are
expensive and require additional development before their results can
be translated into effective clinical care. At this point, the science
to make personalized treatment decisions is available at a level of
confidence only for a handful of diseases. Much work needs to be done
to achieve the ideal of personalized integrative medicine based on
genomic technologies.
CLINICAL RESEARCH
Therapeutic Clinical Trials and Meta-Analysis
To date, the majority of clinical trials in the field of
integrative medicine have focused on evaluating single components from
the system for efficacy in treating a specific medical condition (e.g.,
St. John's Wort for depression, a specific set of acupuncture points
for headaches, a protocol of chiropractic adjustments for low-back
pain, or melatonin for insomnia). It is beyond the scope of this paper
to provide a summary of all the clinical trials conducted in the field,
but a search of Medline resulted in nearly 6,500 randomized controlled
trials under the medical subject heading of complementary therapies,
which was only created in 2002. In some cases, there have been enough
studies on a particular treatment and condition to result in a
systematic review or meta-analysis (nearly 3,000 systematic reviews and
400 meta-analyses are found in Medline when using the complementary
therapies subject heading). The Cochrane Database of Systematic Reviews
has published more than 600 articles related to complementary therapies
as of November 2008. Readers are referred to those reviews for a
summary of findings in clinical trials (Bausewein et al. 2008;
Bjelakovic et al. 2008; Dickinson et al. 2008; He et al. 2007; Horneber
et al. 2008; Maratos et al. 2008; Priebe et al. 2008; Zhu et al. 2008).
A common limitation of several nonpharmacologic interventions is
difficulty with blinding, with the related issue of finding a credible
control intervention. Some of the approaches used in the fields of
surgery and psychology that might be applicable here include blinding
participants to the study hypothesis, use of sham training approaches,
sham procedures, similar attention-control interventions, and blinding
of outcome assessors (Boutron et al. 2007). Incorporating elements of
the CONSORT statement for the nonpharmacologic treatments at the time
of clinical trial design might help with the quality of study design
(Boutron et al. 2008). Taking a broad, patient-centered approach and
including mixed outcomes that evaluate the basic mechanisms (such as
modern imaging studies) and combining them with safety, economic, and
patient relevant outcomes data will likely increase the strength of the
evidence even if the study can only be designed as a single-blind
(investigator) trial. A related issue is the importance of maintaining
objective neutrality on the part of the investigators. This is
particularly so for nonpharmacologic interventions because, for
example, part of the effect of a treatment modality such as the
acupuncture part of the effect may be related to the context and
process of Traditional Chinese Medicine (TCM) (Paterson and Dieppe,
2005).
Identification and inclusion of generalizable molecular markers
that have been correlated with stress and are responsive to stress
management (such as telomerase activity and telomere maintenance
capacity in human immune-system cells) will likely increase the
credibility of study findings and provide more objective surrogate
outcome measures (Epel et al. 2004; Ornish et al. 2008). Incorporation
of noninvasive methods to measure immune system outcome measures will
not increase the disease burden while obtaining additional rich data
(Cizza et al. 2008; Marques-Deak et al. 2006).
A challenging issue in studying biologically based therapies, such
as dietary supplements, is an ability to secure a consistent study
agent with multiple and sometimes unknown active constituents (Harkey
et al. 2001). Careful selection of the study population and endpoints
is crucial for the success of the trial. A structured, well-thought-out
approach needs to be developed so that the limited resources available
are optimally utilized for testing interventions with a high potential
for efficacy (Vickers, 2007), particularly in light of several recent
expensive negative trials with dietary supplements (Atwood et al. 2008;
Bent et al. 2006; Clegg et al. 2006; Shelton et al. 2001; Taylor et al.
2003).
Attention need to be paid to the scope and overall design of the
study with the intent to balance internal validity with external
generalizability. For example, for dietary supplements, phase I/II
trials that might be helpful towards dose establishment and assessment
of safety before embarking on expensive phase III trials (Vickers,
2006; Vickers et al. 2006). For mind-body, energy-based, and manual
interventions, the initial focus should be on creating a structured and
reproducible intervention, consistent with how they are practiced in
real life along with an appropriate control group.
Combining data for a meta-analysis can be particularly challenging
in the field of integrative medicine. For example, there are hundreds
of forms of Qi Gong and each is used traditionally for different
reasons; there are several traditions of acupuncture and many different
needling techniques; herbal preparations can vary greatly depending on
the growing conditions and extraction methods. The appropriateness of
merging such a diverse group of therapies in meta-analysis and the
resultant conclusions is subject to debate.
Whole Systems Research and Multi-Modality Studies
A new trend in integrative medicine research is the push for
``whole systems'' research, which strives to examine the effect of a
multi-modality health care approach to provide individualized
treatment, since this will more accurately evaluate the health care
currently being provided to patients. There are several commentaries in
the literature urging integrative medicine researchers to consider
research methods beyond the RCT (Boon et al. 2007; Cardini et al. 2006;
Fonnebo et al. 2007; Ritenbaugh et al. 2003). One example of whole
systems research is the study by Ritenbaugh et al. who examined the
effect of whole system TCM versus naturopathic medicine versus standard
of care for the treatment of tempromandibular disorders (Ritenbaugh et
al. 2008). In this study, improvement was seen in temporo-
mandibular disorders when participants were randomized to whole systems
treatment interventions beyond that seen in the standard care group
(Ritenbaugh et al. 2008).
Several investigators have discussed the need to use more complex
methods of analysis so that these systems of health care can be
examined, rather than the efficacy of each part of the system (Bell and
Koithan, 2006; Ritenbaugh et al. 2003; Verhoef et al. 2005). Some
suggest using network and complex system analysis as methods for
assessing whole systems research; however, it is critical for
researchers interested in these methods to work with skilled
biostatisticians experienced with these more complex statistical
methods (Bell and Koithan, 2006). Verhoef et al. encourage researchers
to add qualitative measures to studies because they can provide a
source of data for unexpected outcomes and a way to measure the broader
effects of a whole system, such as integrative medicine (Verhoef et al.
2005). It is important for researchers in the field of integrative
medicine to consider the range of effects the treatments may have for
patients, and thus to measure a broad area of outcomes in order to
detect these effects.
BEYOND THERAPEUTIC CLINICAL TRIALS
Individual Resilience and Hardiness
Of the three variables in the triangle of disease causation (agent,
host, and environment), host factors remain suboptimally addressed in
modern medicine. Other medical systems consider strengthening the host
as a primary focus. Resilience and hardiness refer to positive
abilities and skills of an individual in response to stress and
adversity (Rutter, 1987). In adults, the components of ``hardiness''
include: commitment (ability to find meaning in events); control
(belief in internal locus of control); and challenge (belief that
challenging experiences provide an opportunity for learning and growth)
(Kobasa, 1979). In children, three correlates of resilience have been
noted: (1) personality disposition (e.g., humor, critical thinking
skills, problem solving skills, self discipline, internal locus of
control, self-esteem, positive outlook, positive expectancies, and
effectiveness in work, play, and love) (Luthar, 1991; Rutter, 1985,
1987; Werner, 1989); (2) family ties and cohesion; and (3) external
support systems (Garmezy, 1993). Exposure to stress and traumatic
events is common, but, not all of those exposed develop post-traumatic
stress disorder (PTSD) or other negative health outcomes. Hardiness is
correlated with positive health outcomes (Bartone et al. 1989; Ford et
al. 2000; Williams and Lawler, 2001). Individual aspects of resilience
are also associated with positive outcomes (Livanou et al. 2002; Yi et
al. 2008). For example, greater pre-event internal locus of control
prevents PTSD in women giving birth (Soet et al. 2003) and maintaining
treatment gains for patients with PTSD. Resilience is thus an important
concept in the fields of physical, mental, and spiritual health.
Additional research is needed to enhance understanding of hardiness or
resilience factors that protect an individual from developing physical
and emotional illness in the face of stress, to identify optimal
strategies in developing resilience within integrative medicine, and to
identify social factors that can be modified to support hardiness to
promote public health.
Social Factors and Practitioner-Patient Relationship
Social support enhances resilience (Turner et al. 2003; Regehr et
al. 2000; King et al. 1998; Perry et al. 1992). A strong network of
friends was associated with improved survival in the elderly
(Rodriguez-Laso et al. 2007; Giles et al. 2005). The effect of social
support on physical health and longevity may be mediated through
improved depressive symptoms, perception of a better quality of life,
better health care access, improved compliance with treatments,
positive effects on the immune system, a sense of engagement, continued
learning, and a feeling of purpose in life (Ciechanowski et al. 2004;
Cohen et al. 2007; Reichstadt et al. 2007; Schwartz, 2005). Providing
social support to others might have an even greater impact on survival
than receiving social support (Brown et al. 2003). Practitioners can
offer meaningful social support that enhances health outcomes (Fogarty
et al. 1999; Ganz, 2008). When individuals become a caregiver of a
family member with a chronic disease, it is important to assess the
strain and burden of this role and provide support and coping
strategies to help maintain wellness of the caregiver (Honea et al.
2008; Raina et al. 2004; Weitzner et al. 2000).
Integrative medicine emphasizes the importance of the relationship
between practitioner and patient to achieve optimal health and healing
through shared decisionmaking (Merenstein et al. 2005; Quinn et al.
2003). There has already been an enormous body of research in the area
of the doctor-patient relationship (and more broadly, the health
professional and patient) and the process of care (e.g., access,
length, practice patterns, cost). There has also been substantial
research in related areas such as social support (Cohen et al. 2001;
Runyan et al. 1998); communication (Grunfeld et al. 2008; Langewitz et
al. 2002); patient-centered care (Anderson et al. 2003; Mead et al.
2002); empathy (Bikker et al. 2005; Mercer and Howie, 2006; Mercer et
al. 2008); effective ways of promoting behavior change (Barkin et al.
2008; Bell and Cole, 2008; McCambridge et al. 2008); different types of
clinical encounters (e.g., individual versus group; in-person versus
telephone or internet) (Hersh et al. 2001; McConnochie et al. 2006;
Modai et al. 2006); patient satisfaction (Esch et al. 2008; Marian et
al. 2008; Mermod et al. 2008); trust (Hall, 2006; Hall et al. 2002);
and team-building and shared governance (Hope et al. 2005; Sierchio,
2003). To date, little of this research on the processes of
relationship-based care has been synthesized and integrated into the
field of integrative medicine. For example, research on acupuncture now
often includes placebo needles, but has not examined closely the
process of building the relationship between therapist and patient or
compared the processes of care provided by acupuncturists with that
provided by other practitioners; nor have comparisons been made about
the relationships among team members on traditional medical
multidisciplinary teams (e.g., clinician, nurse, social worker,
physical therapist, occupational therapist) with integrative teams
(e.g., naturopathic practitioners, nutritionists, acupuncturists,
massage therapists).
Patient's Participation In Self-Care
How to inspire, motivate, empower, and facilitate patient self-care
is an important issue in integrative medicine. Self-care is a two-
dimensional construct that includes processes for health in self-care
practice and action capabilities (Hoy et al. 2007). The processes
include life experience, learning processes, and ecological processes.
Action capabilities include power and performance capabilities.
The primary aim of inspiring, motivating, and empowering patients
is towards a single goal--being able to bring about a positive behavior
change. Several models have been developed to address behavior change.
These include models based on attachment theory (Ciechanowski et al.
2001); the chronic care model (Bodenheimer et al. 2002); (Wagner,
1998); the extended parallel process model (Gore and Bracken, 2005);
the health belief model (Champion, 1984; Jones et al. 1987); the
problem solving model (Alley and Brown, 2002; Peter et al. 2006); the
self management model (Price, 1993; Walker et al. 2003); social
cognitive theory (Anderson et al. 2007; Hortz and Petosa, 2008); the
transtheoretical model (Prochaska, 2006; Prochaska and Velicer, 1997);
and the theory of reasoned action (Feeley, 2003; Hedeker et al. 1996).
A common theme that emerges from a critical evaluation of all these
models is that a planned intervention should ideally incorporate
several essential components for successful behavior change. The two
steps in this process involve assessment and action. Components of
assessment include ascertaining the need for behavior change,
resources, individual perception of need for change, and self efficacy.
Most of these models were developed to address a specific medical
condition. There exists a need to test behavior change models within
the context of multiple complex medical conditions that is
representative of the patient population today.
Comprehensive, integrative treatments recommendations, even for
patients with a single diagnosis, involve lifestyle modifications as
well as medications, resulting in complex, multifaceted treatment plans
(Bell and Kravitz, 2008). Although most research on adherence has
focused on medications, little is known about the impact of combining
advice about medications with advice about other lifestyle factors on
adherence to the pharmaceutical regimen. Lifestyle counseling appears
to increase patient satisfaction, but its overall impact on cost of
care and adherence is largely unknown (Harting et al. 2006; Johansson
et al. 2005). Furthermore, adherence to specific recommendations may
vary according to patients' explanatory models (Abraham et al. 2004).
For example, patients who believe their hypertension is related to
stress may be more adherent to recommendations about stress management,
while patients who believe their blood pressure is purely a genetic or
biochemical problem may be more adherent to pharmaceutical regimens
(Hekler et al. 2008). Similarly, patients may invoke biochemical,
genetic, personality, stress, cognitive, karmic, spiritual,
environmental, weather-related, astrological, or energetic
explanations, or some combination of these factors for their symptoms
and experiences. Different explanatory systems could have dramatically
different impacts on patients' willingness to embark on or adhere to
different treatment regimens. Research on how to best match patients'
explanatory models and disease pathophysiology with optimal treatment
options and the impact of matching/mismatching on adherence, clinical
outcomes, and satisfaction with care and cost of care is needed.
The Global Village--Health Care And Societal Consequences
Integrative medicine looks beyond individual health behaviors to
larger environmental, social, and educational factors affecting health.
Research has begun to
establish the critical role of the environment on human health (Diaz,
2007; Johnson et al. 2008; Usta et al. 2008; Wilkinson, 2008). Research
will play an important role in determining the most effective,
efficient, and equitable strategies for translating new knowledge about
environment into integrative clinical practice. Providing conventional
health care also impacts the environment (e.g., pharmaceuticals
contaminating drinking water supplies; biological and technical waste
disposal; incineration of mercury, PVC, and other products) which in
turn affects human health (Barnes et al. 2008a; Gaudry and Skiehar,
2007; Hiltz, 2007; Rabiet et al. 2006; Tudor et al. 2008; Zakaria and
Labib, 2003). Integrative medicine explicitly attempts to provide care
that is ``green'' and health promoting; the extent to which integrative
care is more environmentally friendly than conventional care is
unknown. Furthermore, there is strong evidence that stress adversely
affects health; yet little research has addressed ways in which health
care institutions can effectively improve their environment, reducing
stress for both clinicians and patients. Finally, it is well known that
social support mitigates against the pernicious effects of many
stressors, and some hospitals (such as pediatric hospitals) have made
efforts to improve family support (e.g., individual rooms allowing
family members to remain with patients), yet there has been little
systematic research on the most cost-effective strategies to improve
social support for patients, family members, clinicians, or staff
within health care institutions or the impact of such changes on health
outcomes. Research is needed to address ways in which integrative
health care providers and institutions can reduce their adverse
environmental impacts and promote positive healing environments while
providing high quality affordable, effective, comprehensive care.
Furthermore, advances in media, communication, commerce, and
transportation technologies have resulted in well-documented changes in
health behaviors (e.g., decreases in fruit and vegetable intake,
increases in sedentary behavior); access to health information and
misinformation; and access to health services (e.g., internet
counseling, international travel for surgical procedures, telemedicine)
(Breckons et al. 2008; Ebrahim et al. 2007; Houpt et al. 2007; Khazaal
et al., 2008; Nava et al. 2008; Trotter and Morgan, 2008; Tsitsika et
al. 2008), and professional education. Integrative medicine has been a
leader in providing online courses (e.g., through the University of
Arizona Center for Integrative Medicine) (Beal et al. 2006; Hadley et
al., 2007; Kemper et al. 2006). Research is needed to determine the
most cost-effective and equitable strategies to provide integrative
medicine and health education using modern telecommunications including
telephone, internet, webinars, and teleconferences for both individual
and group models.
Social policies also profoundly affect health, and integrative
medicine, as a holistic discipline, must include research to better
understand the impact of health policies on overall health. For
example, public energy policies that promote the use of coal-fired
power plants (resulting in mercury-contaminated fish); agricultural
policies that promote monocultures of corn, wheat, and soy (resulting
in inexpensive and obesogenic diets); educational policies that rely on
income from vending machines in schools (providing unhealthy
nutritional options); school lunch programs (providing less than
optimal nutrition); transportation policies that promote automobile
rather than public transportation (increasing sedentary behavior as
well as promoting global climate change); and zoning policies that
promote sprawl all have important health consequences. Little research
has been conducted to evaluate the health consequences of variations in
social policies about agriculture, transportation, education, or
energy. Such studies might include regional comparisons in the United
States or comparisons of the effects of policy variations between
countries and over time on broad health outcomes.
Also, public policies that affect payments for certain kinds of
health care providers (e.g., M.D., DO, DC) and a few kinds of therapy
(e.g., prescription drugs and surgery) may have very different impacts
on health outcomes, as compared to policies promoting payment for
fitness club memberships, massage, and nutritional supplements. Little
research to date has examined the effects of different reimbursement
plans on health outcomes. Furthermore, most fee-for-service plans
provide professional payments based on RVUs and DRGs, rather than on
health outcomes (e.g., whether or not they help patients feel better or
function more productively). Our reimbursement schemes favor short,
repeated visits in which patient health does not necessarily improve.
Research showing the benefits of certain kinds of care (e.g., patient-
centered, good communication skills, stress reduction coaching,
lifestyle coaching) in the absence of policies supporting their
financial viability appear unlikely to be sustainable. Thus, research
is needed regarding the effective translation of knowledge about the
environment and behavior into effective social policies and
reimbursement schemes.
Setting Priorities for the Integrative Medicine Research Agenda
FRAMEWORK TO SET PRIORITIES
Given the large number of research areas that need to be addressed
and limited resources, a systematic approach to prioritizing projects
is needed. A model has been proposed that includes attention to high
priority conditions, populations, therapies, and a comprehensive view
of important outcomes (Kemper et al. 1999).
Conditions
Priority should be given to conditions and diseases that satisfy
the criteria in Table 1: those that impose a heavy burden of suffering
to patients and costs to society for which current therapies are
insufficient and for which integrative approaches offer a reasonable
likelihood of being helpful and are already in use. Examples include
anxiety, asthma, attention deficit disorder, back pain, cancer,
cardiovascular diseases, chronic and severe pain syndromes, depression,
developmental disorders, insomnia, obesity/metabolic syndrome,
recurrent respiratory infections, rheumatic and autoimmune disorders,
and addictive disorders.
Table 1.--Criteria for Conditions, Diseases, and Risky Health Behaviors
With High Priority for Integrative Medical Research
------------------------------------------------------------------------
-------------------------------------------------------------------------
Those that:
Impose a heavy burden of: suffering on individuals, families or the
community either because of their severity, chronicity, or
prevalence; and
For which current mainstream therapies are unacceptable or
insufficient because of: lack of proven efficacy, substantial side
effects, cost, or lack of availability; or
Which integrative medicine offers a reasonable likelihood of being
helpful based on: proven safety in animal models, and lengthy
historical use or compelling results from case reports, case series,
epidemiologic studies, case-control trials or cohort studies, or
clear scientific rationale; and
Which families and practitioners are already using integrative
approaches.
Therapies
Therapies requiring additional professional intervention are also
priorities for research because of the substantial costs associated
with professional care. Thus, research on the effectiveness, safety,
and costs of chiropractic, acupuncture, electroencephalographic
biofeedback, hypnosis, or other mind-body techniques requiring licensed
professional therapists should be high priorities (Vas et al., 2006;
Wasiak and McNeely, 2006; Thomas et al. 2005). CAM practitioners,
including spiritual healers, who advocate abandoning conventional
medical care (e.g., transfusions or immunizations) also require
investigation into the scope of their effect on individual health
practices and overall public health (e.g., increased rates of vaccine
preventable illnesses). Research on interventions (e.g. certain natural
products) that have already been supported by a substantial amount of
preliminary data and are on the verge of definitive evidence for
widespread clinical application should also enjoy priority, as such
research is likely to be a high yield investment.
Types of Research Synthesis
Given the often conflicting data from medical research studies,
overviews and data synthesizing analyses are critically important for
translating research into practice. The Cochrane Collaboration and
others have made important contributions to this field over the last 10
years, and additional analyses providing specific guidance to
practicing clinicians, policymakers, and researchers is needed (Dorn et
al. 2007; Gagnier et al. 2006; Lawson et al. 2005; Pham et al. 2005).
Outcomes
Outcomes include not only traditional measures of morbidity,
mortality, cost of care, and patient satisfaction, but also the impact
of care on family cohesiveness, cultural identity, spiritual beliefs,
resilience, coping, and self-efficacy. The impact on the environment
also should be considered. Additional outcome measures may need to be
developed to address the concept of health as optimal functioning
rather than as the absence of disease and to address patient
priorities, particularly when there are multiple co-existing
priorities.
Table 2.--Outcomes of Interest in Research on Integrative Medicine
------------------------------------------------------------------------
-------------------------------------------------------------------------
Patient outcomes:
Mortality rates, years of life saved
Morbidity--physical, psychological, emotional and social symptoms;
severity of illness
Health behaviors--dietary, exercise patterns; smoking, drinking, and
drug use; unprotected sexual relations
Health care utilization, including self-care, CAM care, and
conventional care
Satisfaction with care
Developmental milestones and behavior
Activities of daily living
Quality of life
Costs associated with care
Direct and indirect financial costs; opportunity costs of missed
treatments; side effects--symptomatic and asymptomatic organ
dysfunction, injuries, infection; adverse interactions with other
therapies; X-ray and other toxic exposures
Social outcomes--Days of work/school missed; delinquency,
incarceration
Family outcomes:
Days of work missed; out-of-pocket costs; impact on insurability
Psychosocial impact on families; emotional impact on sense of
empowerment
Spiritual outcomes: coping, peace, serenity, harmony in relationships,
a sense of meaning or purpose in life, self-efficacy, self-esteem.
Social outcomes: divorce, employment, bankruptcy
Community outcomes:
Sense of cohesiveness, cultural identity; social capital
Cost to society, rate of malpractice suits
Environmental impact: cost of remedy to society, environment,
(overharvesting of herbs leading to extinction; climate change;
pollution)
Provider outcomes:
Provider satisfaction with role
Burnout
Sense of effectiveness and part of healing community
The following sections discuss specific areas of research for
discussion in setting priorities.
SPECTRUM OF LIFE CYCLE
Integrative medicine can be provided to patients across the
demographic spectrum of age, gender, and race/ethnicity, and there may
be disparities in the availability and quality of services to different
populations (Demattia et al. 2006). Integrative care can also be
provided for prevention, acute, and chronic illness as well as
rehabilitation and palliation. Among the most vulnerable populations
which have been least studied are children, adolescents, and patients
suffering from genetic or congenital disorders. Other research
populations that should be considered as high priorities include women
across the life cycle, not only during pregnancy and breast-feeding,
but also through the different phases of the menstrual cycle, at
menarche and through menopause (particularly during pregnancy and
breastfeeding periods), the frail elderly, patients with complex
conditions and multiple comorbidities, patients at the end of life,
those with limited access to care, and patients from diverse cultural/
ethnic backgrounds. It is also important to study gender differences of
the various interventions, not only in women, but also the differential
effects of these interventions in men and women.
EPIDEMIOLOGICAL STUDIES
With the development of large integrative clinics at medical
institutions across the country, epidemiological methods can be used to
generate novel data. A number of these institutions have begun
collecting outcomes data on their patients to allow for prospective
studies of integrative medicine, ``The Outcomes Research Project''
(Sierpina, 2008). In addition to outcomes data, it would be useful for
these clinics to create registries of their patients to gather data on
the specifics of the integrative treatments received by each patient.
In order to conduct controlled cohort studies, it is essential that
these centers identify an appropriate source of control patients whose
use of CAM therapies and the use of integrative medicine clinics has
been documented. If existing patient registries (such as the Cystic
Fibrosis Foundation Patient Registry or the National Cancer Institute's
Surveillance, Epidemiology and End Results Program) systematically
collected data on integrative medicine, they could provide an excellent
source of data for cohort studies to compare the benefits and/or risks
of integrative medicine.
Another type of research that should be encouraged in the field of
integrative medicine is health services research (Coulter and Khorsan,
2008; Herman et al. 2006). Descriptive studies are needed to determine
how providers practice integrative medicine, what patients seek care
from integrative medicine clinics, the benefit patients receive from
integrative medicine, and the cost effectiveness of integrative
medicine (Cardini et al. 2006; Coulter and Khorsan, 2008; Fonnebo et
al. 2007; Herman et al. 2006). Some researchers suggest that before
conducting studies of efficacy of individual components of integrative
medicine, pragmatic research should demonstrate the effectiveness of
this medicine in the real world setting. If the system of integrative
medicine is found to be effective, future studies can then examine the
components of the whole system to determine if they are efficacious
individually or only in combination. Individual components found to be
efficacious could be further explored to determine their biological
mechanism (Coulter and Khorsan, 2008; Fonnebo et al., 2007).
Finally, epidemiological studies would be wise to gather data about
CAM use. Some forms of CAM use may confound findings of cohort and
case-control studies. Several large meta-analyses have documented that
individual vitamins can impact all causes of mortality (Autier and
Gandini, 2007; Melamed et al. 2008; Miller et al., 2005; Omenn et al.
1996). Examining the possible confounding effects of these treatments
is not possible if the data are never collected by researchers. Use of
CAM therapies also needs to be studied for clinical research
participants in order to decrease risks of interactions (Welder et al.
2006).
BASIC SCIENCE, MECHANISTIC STUDIES
The value of basic science research in integrative medicine lays in
its ability to increase knowledge and understanding of how fundamental
biological processes work. Some argue that the danger of taking the
molecular approach to the extreme loses sight of the complex,
interactive nature of human diseases and behaviors. Integrative
medicine researchers should guard against this. On the other hand,
basic science research is essential to elevate the level of research
and broaden the impact of integrative medicine.
Among the areas which should be considered as priorities are the
following:
1. Genomic/proteomic/pharmacogenetic studies investigating the
individuality of patients despite sharing the same disease process.
Such knowledge can be used to develop a personalized health care
approach to disease prevention and treatment;
2. System biology studies to identify and characterize the
interactions between multiple components of the biological processes
and the interactions between mind and body. Research in this area will
create new appreciation of the interconnect-
iveness of various components in human health and lead to therapeutic
strategies that take advantage of such knowledge; and
3. Research on how behavioral interventions can change biological
processes at the molecular and cellular level. This would create more
effective tools for further behavior modifications relevant to
reversing human diseases.
DIAGNOSTIC TECHNIQUES
An area in need of further research is a critical assessment of the
many novel laboratory assessments intended for evaluation of biomarkers
indicative of disease risk, prognosis, or treatment options. Because of
the novelty of these tests, little or no data exists about their
sensitivity and specificity, making interpretation of results
difficult. In some cases, the tests offered are not diagnostic but
rather informative of the individual, with their clinical
meaningfulness unknown. In these cases, detailed information on the
calculation of the normal ranges is often lacking in the test
descriptions. Some novel laboratory tests may become the new standard
of diagnosis or tool for monitoring effectiveness of treatment. However
until more research documents their validity and reliability, these
tests will continue to be considered experimental.
CLINICAL INTERVENTIONS
Study Design
The paradigm of pragmatic (effectiveness) vs. explanatory
(efficacy) studies is still relevant today, particularly in integrative
medicine (Gartlehner et al. 2006; Schwartz and Lellouch, 1967). The
pragmatic nature of a larger RCT, even one with few restrictions for
enrollment, however, is still limited since the complex variables that
go into individual decisionmaking often cannot be controlled in
clinical trials setting (Karanicolas et al. 2008). For research to be
integrative, it will be important to define the real world contexts in
which the results are to be applied. Another important issue here is
the selection of appropriate outcome measures. Wherever possible,
patient relevant variables should be included in pragmatic trials, not
just surrogate outcome measures (Montori et al. 2007). The basic
elements of study design and conduct need to be addressed adequately
(Bloom et al. 2000). Even with a good study design, a single neglected
issue could seriously impact the validity of the results (Pittler and
Ernst, 2004). For research to have a meaningful impact on integrative
patient care, the investigator should focus on conducting well-designed
studies with minimal bias, keeping particular aspects of the
intervention in mind, while also being mindful of the appropriate stage
of research (pragmatic vs. explanatory).
Personalized and Holistic Health Care
In keeping with the goal of patient-centered holistic care in
integrative medicine, future research should consider going beyond
studying individual modalities for specific disease indication. In a
holistic view, many human diseases are connected through hub processes
underlying the pathological processes. Some of these processes have
been identified, others have not. This connection has been
underappreciated in a reductionist research approach, but quite
commonly reflected in the narratives of many traditional medical
systems. Systems biology research has shown that one possible mechanism
of such ``human disease network'' is shared disorder-gene associations
(Cusick et al. 2005). A bipartite human metabolic disease association
network has been created in which nodes are diseases and two diseases
are linked if mutated enzymes associated with them catalyze adjacent
metabolic reactions (Lee et al. 2008). The model shows a network
topology for disease comorbidity (Goh et al. 2007). Integrative
medicine research can similarly use mathematical models to explore
other such connections based perhaps not on genes, but on other
functional variables (Bell and Koithan, 2006; Verhoef et al. 2005;
Verhoef et al. 2006b).
To emphasize patient-centered care, future integrative medicine
research should take advantage of technological advancements to
individualize intervention and outcome assessment (Snyderman and
Langheier, 2006). Application of pharmaco-
genetics knowledge to herbal medicine trials may result in a better
selection of the study population, hence reduce sample size and
increase the effect size, leading to more efficient use of research
resources and minimizing the number of falsely negative trials (Arab et
al. 2006; Fernandes, 2008). Computerized patient-centered outcomes
assessment networks would produce efficacy endpoints. These endpoints
should take into consideration patients' priorities in wellness, be
more clinically relevant, and be consistent with the goal of
integrative medicine (Kaasa et al. 2008).
Patient expectations and beliefs about therapies are intricately
linked to their explanatory models and sense of meaning (Cohen, 2003;
Di Blasi et al. 2001). New methods and tools are being devised to
assess patients' beliefs and attitudes, but these have not been widely
implemented (Dennehy et al. 2002; Lewith et al. 2002; O'Callaghan and
Jordan, 2003). Similarly, different practitioners' expectations,
beliefs, values, and explanatory models are likely to affect the kinds
of diagnostic evaluations, counseling, and treatments offered to
patients (Armbruster et al. 2003; Curlin et al. 2007; Saal, 2002). In
addition, patients may have different values and priorities in
addressing their symptoms, and attention to these priorities may affect
satisfaction with care and adherence to recommendations (Ammentorp et
al. 2005). For example, different patients who have hypertension,
allergies, insomnia, anxiety, and chronic pain may have different
priorities for treatment--one may focus on hypertension while another
may be more focused on pain or insomnia or anxiety. The same patient
may have different priorities at different times or when accompanied to
the visit with different family members who are affected by the
patient's condition.
The complex issues inherent in providing patient-centered
integrative care in the context of multiple conditions in patients with
different priorities, values, expectations, and beliefs are poorly
understood. It is possible that new research paradigms will be needed
to address this lack of knowledge, not only for clinical outcomes, but
for satisfaction with and cost of care for patients, as well as the
impact on
practitioners (e.g., burnout and fatigue) and the public's health
(e.g., overall health care costs, impact on work/school, activities of
daily living).
Promoting Self Care and Individual Resilience
To encourage behavior changes and promote self care, the planned
integrative action has to be multi-dimensional. Optimal use of skills
in motivational interviewing for patients in the pre-contemplative or
contemplative stages is likely to help (Hettema et al. 2005). Mind-body
interventions that are likely to help develop resilience include mind-
body modalities such as relaxation, hypnosis, visual imagery,
meditation, yoga, tai chi, qi gong, cognitive-behavioral therapies,
group support, autogenic training, and spirituality. In addition to
these approaches, cultivating compassion, forgiveness, gratitude, and
finding meaning and purpose to one's life are also important towards
developing contentment and happiness and thus fostering resilience
(Brass et al. 2003; Farrow et al. 2001). Optimal disease management,
nutrition, physical exercise, and restorative sleep are also likely to
foster resilience. Interventions primarily aimed to foster resilience
are beginning to be tested in clinical trials. These studies mostly
show promising results and have involved patients with diabetes
(Bradshaw et al. 2007), are conducted as work site interventions (Waite
and Richardson, 2004), include college students with academic stress
(Steinhardt and Dolbier, 2008), or take place in school settings (Ruini
et al. 2006). Early studies suggest that resilience might correlate
with selective activation of the left prefrontal cortex (Davidson,
2000). This needs to be further validated. Integrative models for
behavioral change need to be developed and tested to motivate patients
with multiple complex medical problems for a sustained change in
behavior. Research into designing and testing resilience interventions
incorporating the wisdom of alternative healing systems and further
understanding the neurobiology of resilience has the potential to
transform patient care.
Practitioner-Patient Interaction and Partnership
A more integrative approach towards patient care entails
incorporating biopsychosocial interdisciplinary content emphasizing
compassion, communication, mindfulness, respect, and social
responsibility (Wear and Castellani, 2000). A core aspect of
integrative medicine is the importance of the relationship between
practitioner and patient (Chang et al. 1983; Quinn et al. 2003) that
has been incorporated into the evolving concept of ``relationship-
centered care.'' Relationship-centered care focuses on the importance
of human relationships with experience of the patient being at the
center of care. The onus of initiating this process rests on the
practitioner. The two key skills for the practitioner to facilitate
this form of care are to cultivate professionalism and humanism (Klein
et al. 2003). The impact of training clinician healers is beginning to
be investigated (Miller et al. 2003; Novack et al. 1999) and is a ripe
area for future research in integrative medicine. Such an approach is
likely to enhance the nonspecific therapeutic effect of a medical
encounter.
In a clinical trial, patients improve for multiple reasons. These
include spontaneous remission, natural course, regression to the mean,
biased reporting, nonspecific therapeutic effects, and specific
therapeutic effects. The nonspecific therapeutic effect, which may
account for improvement in up to 60 percent of patients for some
conditions (Kaptchuk et al. 2008), has been considered more a nuisance
than a useful therapeutic effect because of the need to control within
the context of placebo-controlled trials for pharmacologic treatments.
However the efficacy observed in the placebo arm may sometimes be
significantly superior to no treatment or standard medical care
(Brinkhaus et al. 2006; Haake et al., 2007; Linde et al. 2005; Melchart
et al. 2005). The skills of professionalism and humanism within an
integrative encounter are likely to increase this nonspecific effect.
Instead of considering the placebo effect as of secondary
importance, it might be more apt to consider the placebo effect as
''contextual healing,'' an aspect of healing that has been produced,
activated, or enhanced by the context of the clinical encounter (Miller
and Kaptchuk, 2008). Variables that maximize contextual healing include
the environment of the clinical setting, cognitive and affective
communication of practitioners, and the ritual of administering the
treatment (Kaptchuk, 2002). Integrating research efforts towards
harnessing the nonspecific therapeutic effect rather than controlling
for it is likely to offer expanded tools and additional insight into
patient care. In situations where it is important to separate the
specific effect from ``contextual healing,'' optimal effort needs to be
placed towards validating a placebo control prior to pursuing large
multi-center trials.
Recommendations for Action
The ultimate goal of integrative medicine research is to guide
clinical practice, thereby maximizing benefit and minimizing patient
risks. When formulating clinical guidelines, two factors are in play:
strength of evidence and burden/risk to and effectiveness and clinical
decisions have to be made with limited information, burden and risk to
the patient need to be taken into account. Although the highest level
of evidence is desirable for every health intervention, it is simply
not possible to achieve this goal. Limited research resources have to
be allocated according to priorities. Therefore, interventions or
therapies with high risk or burden (economic/ time/effort) to patients
and society must meet a high standard in strength of evidence, often in
the form of multiple RCTs, to be utilized in clinical practice.
Those with low or little risk/burden can be incorporated into
practice even when the highest level of evidence is not available
(McCrory et al. 2007). Such an approach can be summarized in a simple
2x2 table (Table 3) about how to decide whether or not to use a
particular therapy based on safety and effectiveness. Implicit in this
model is the notion that the clinician and patient both understand and
agree on the problem; the goal of therapy; the evidence regarding
safety and effectiveness of the therapy being considered; the extent to
which it is accessible, affordable, and of high and consistent quality;
and availability of similar information about alternative treatments
(or a combination of treatments) under consideration.
In light of this relationship between research and clinical
practice and the issues discussed in Sections on Context and on Setting
Priorities, we make the following recommendations for action regarding
integrative medicine research. We suggest the actors for each
recommendation be discussed at the IOM Summit on Integrative Medicine
and the Health of the Public. Key stakeholders need to be identified to
make it a collaborative, multidisciplinary effort for each item--
including researchers, patients, and policymakers.
1. Identify pressing areas of research in integrative medicine and
define the level of evidence required for their clinical applications.
2. Establish a consortium of integrative medicine researchers to
form consensus on how to implement the research priorities as follow-up
to this summit.
3. Build an international information technology platform which
standardizes and facilitates data acquisition, data banking, and
communication between researchers to achieve synergy of productivity.
4. Demonstrate the value of integrative medicine in health
maintenance and disease prevention to policy making bodies, especially
in light of the current economic setting of burgeoning health care cost
to society, so that more resources can be allocated to integrative
medicine research.
Table 3.--Benefit and Risk Ratio and Selection of Therapies
----------------------------------------------------------------------------------------------------------------
Effective
-------------------------------------------------
Yes No
----------------------------------------------------------------------------------------------------------------
Safe Yes.................... Use.................... Tolerate
No..................... Monitor................ Avoid
----------------------------------------------------------------------------------------------------------------
We propose the following questions to be discussed during the
summit.
1. What are the three most important research questions in
integrative medicine as a whole?
2. What should be the top three research priorities in integrative
medicine in the setting of limited research resources?
3. What progress would you like to see made in integrative medicine
research in the next 3-5 years?
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Prepared Statement of Ron Z. Goetzel, Ph.D., Research Professor and
Director, Institute for Health and Productivity Studies, Rollins School
of Public Health, Emory University; Vice President, Consulting and
Applied Research, Thomson Healthcare
Good afternoon. I would like to thank the committee for inviting me
to submit this written statement on the subject of the health and
financial benefits of workplace health promotion and disease prevention
programs. My name is Ron Goetzel. I have been involved in research
focused on worksite health promotion programs for the past 20 years
while employed at Johnson & Johnson, Thomson Reuters (formerly
Medstat), Cornell University, and Emory University.
Over the past 20 years, my work has focused on large-scale
evaluations of health promotion, disease prevention, demand and disease
management programs. My evaluations have been conducted in partnership
with large employers including Applied Materials, Boeing Company,
Chevron, Citibank, The Dow Chemical Company, Johnson & Johnson, IBM,
Procter & Gamble, Florida Power & Light, Duke University, Pepsi
Bottling Group, Prudential Financial, Union Pacific Railroad, Sharp
Health Care, Novartis, Highmark, General Electric, Ford, Motorola,
Lucent, International Truck and Engine, First Tennessee Bank, and Texas
Instruments.
DEFINING WORKSITE HEALTH PROMOTION
Before going any further, I'd like to define worksite health
promotion programs for the committee. Worksite health promotion
programs are employer initiatives directed at improving the health and
well-being of workers and, in some cases, their dependents. They
include programs designed to avert the occurrence of disease or the
progression of disease from its early unrecognized stage to one that is
more severe. At their core, worksite health promotion programs support
primary, secondary, and tertiary prevention efforts.
Primary prevention efforts in the workplace are directed at
employed populations that are generally healthy. Examples include
programs that encourage exercise and fitness, healthy eating, weight
management, stress management, use of safety belts in cars, moderate
alcohol consumption, and recommended adult immunizations.
Health promotion also incorporates elements of secondary prevention
directed at individuals already at high risk because of certain
lifestyle practices (e.g., smoking, being sedentary, having poor
nutrition, consuming excessive amounts of alcohol, and experiencing
high stress) or abnormal biometric values (e.g., high blood pressure,
high cholesterol, high blood glucose, being overweight or obese).
Examples of secondary prevention include hypertension screenings and
management programs, smoking cessation coaching, weight loss
interventions, and reduction or elimination of financial barriers to
obtaining evidence-based pharmaceutical treatments.
Health promotion sometimes also includes elements of tertiary
prevention, often referred to as disease management, directed at
individuals with existing ailments such as asthma, diabetes,
cardiovascular disease, cancers, musculoskeletal disorders, and
depression, with the aim of ameliorating the disease or retarding its
progression. Such programs promote better compliance with medications
and adherence to evidence-based clinical practice guidelines for
outpatient treatment. Because patient self-management is stressed,
health-promotion practices related to behavior change and risk
reduction are often part of disease management protocols.
ESTABLISHING A BUSINESS CASE FOR HEALTH PROMOTION
The Centers for Disease Control and Prevention (CDC), in
conjunction with its Healthy People in Healthy Places initiative, has
observed that workplaces are to adults what schools are to children,
because most working-age adults spend a substantial portion of their
waking hours at work. The question for employers is whether well-
conceived worksite health promotion programs can improve employees'
health, reduce their risks for disease, control unnecessary health care
utilization, limit illness-related absenteeism, and decrease health-
related productivity losses.
There is growing evidence that the answer is ``yes.'' Here is the
logic for increased investment in health promotion:
1. Many of the diseases and disorders from which people suffer are
preventable.
2. Modifiable health risk factors are precursors to a large number
of these diseases and disorders.
3. Many modifiable health risks are associated with increased
health care costs and reduced worker productivity, within a relatively
short time window.
4. Modifiable health risks can be improved through theory-based
health promotion and disease prevention programs.
5. Improvements in the health risk profile of a population can lead
to reductions in health care costs and absenteeism, and heightened
worker productivity.
6. Well-designed and well-implemented worksite health promotion and
disease prevention programs can save money, and in our research
actually produce a positive return on investment (ROI).
I would now like to highlight some of the salient studies
supporting these points.
Many Diseases and Disorders are Preventable, Yet Costly
A large body of medical and epidemiological evidence shows the
links between common, modifiable, behavioral risk factors and chronic
disease.\1\ Preventable illnesses make up approximately 70 percent of
the total burden of disease and their associated costs.\1\ Half of all
deaths in the United States are caused by behavioral risk factors and
behavior patterns that are modifiable.\2\ \3\ In particular, the United
States has been witnessing alarming increases in obesity, diabetes, and
related disorders for many years.\4\ These diseases strain the
resources of the health care system, as individuals who experience them
generate significantly higher health care costs.\5\
Modifiable Health Risks Increase Employer Costs
Analyses by Anderson, et al.\6\ show that 10 modifiable health risk
factors account for approximately 25 percent of all health care
expenditures for employers. Moreover, employees with seven risk factors
(tobacco use, hypertension, hyperchol-
esterolemia, overweight/obesity, high blood glucose, high stress, and
lack of physical activity) cost employers 228 percent more than those
lacking those risk factors.\7\ Workers with these risk factors are more
likely to be high-cost employees in terms of absenteeism, disability,
and reduced productivity.\8\
Workplaces Offer an Ideal Setting for Health Promotion
Most people agree that the workplace presents an ideal setting for
introducing and maintaining health promotion programs. The workplace
contains a concentrated group of people, who share a common purpose and
common culture. Communication and information exchange with workers are
relatively straightforward. Individual goals and organizational goals,
including those related to increasing productivity, are generally
aligned with one another. Social support is available when behavior
change efforts are attempted. Organizational norms can help guide
certain behaviors and discourage others. Financial or other incentives
can be introduced to encourage participation in programs. Measurement
of program impact is often practical using available administrative
data collection and analysis systems.
Worksite Health Promotion Can Positively Influence Employees' Health
Risks
An important question to consider is whether worksite programs can
change the risk profile of workers. Here again, the evidence points to
a positive result. Catherine Heaney and I examined 47 peer-reviewed
studies, over a 20-year period, focused on the impact of multi-
component worksite health promotion programs on employee health and
productivity outcomes.\9\ We concluded that there was ``indicative to
acceptable'' evidence supporting the effectiveness of multi-component
worksite health promotion programs in achieving long-term behavior
change and risk reduction among workers. The most effective programs
offered individualized risk-reduction counseling, coaching and self-
management training to the highest risk employees within the context of
a healthy company culture and supportive work environment.\9\
More recently, the CDC Community Guide Task Force released the
findings of a comprehensive and systematic literature review focused on
the health and economic impacts of worksite health promotion.\10\ \11\
Health and productivity outcomes from worksite interventions were
reported from 50 studies. The outcomes included a range of health
behaviors, physiologic measurements, and productivity indicators linked
to changes in health status. Although many of the changes in these
outcomes were small when measured at an individual level, such changes
at the population level were considered substantial.
Specifically, the Task Force found strong evidence of worksite
health promotion program effectiveness in reducing tobacco use among
participants, dietary fat consumption, high blood pressure, total serum
cholesterol levels, the number of days absent from work because of
illness or disability, and improvements in other general measures of
worker productivity. Insufficient evidence of effectiveness was found
for some desired program outcomes, such as increasing dietary intake of
fruits and vegetables, reducing overweight and obesity, and improving
physical fitness. But overall, the Community Guide review came up with
very positive findings related to health and economic outcomes from
workplace health promotion programs.
Worksite Health Promotion Can Achieve a Positive Return on Investment
There is now a growing body of evidence suggesting that worksite
programs can also save money and even pay for themselves. Several
literature reviews that weigh the results from experimental and quasi-
experimental research studies suggest that programs grounded in
behavior change theory, and ones that utilize tailored communications
and individualized counseling for high-risk individuals, achieve cost
savings and produce a positive return on investment.\12\ \13\ \14\ The
ROI research is grounded in evaluations of employer-sponsored health
promotion programs. Studies often cited with the strongest research
designs and large numbers of subjects included those performed at
Johnson and Johnson,\15\ \16\ Citibank,\17\ Dupont,\18\ the Bank of
America,\19\ \20\ Tenneco,\21\ Duke University,\22\ the California
Public Retirees System,\23\ Procter and Gamble,\24\ and Chevron
Corporation.\25\ In a widely cited example of a rigorous ROI analysis,
Citibank reported a savings of $8.9 million in medical expenditures
from its health promotion program as compared to a $1.9 million
investment, thus achieving an ROI of $4.56 to $1.00.\17\ A recent
contribution to the ROI literature can be found in a study published in
the February 2008 issue of the Journal of Occupational and
Environmental Medicine which reported a $1.65 to $1.00 ROI for a
worksite program put in place at Highmark, a health plan in
Pennsylvania.\26\ Even accounting for certain inconsistencies in design
and results, most of these worksite programs have produced positive
financial results.
CONCLUSION
In summary, I have put forth some of the main arguments and
supportive scientific evidence in favor of increased employer
investment in health promotion programs. I believe that these programs
will not only improve the health and productivity of U.S. workers but
also save money in the long run.
Thank you again for your time and attention and I welcome your
questions and comments.
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(2008) The Impact of the Highmark Employee Wellness Programs on Four-
Year Healthcare Costs. Journal of Occupational and Environmental
Medicine, 50:2, February 2008, 146-156.
Prepared Statement of Kathi J. Kemper, M.D., M.P.H., FAAP; Caryl J.
Guth Chair for Complementary and Integrative Medicine; Professor of
Pediatrics; Family and Community Medicine; Social Science Health
Policy; Regenerative Medicine; Bioethics and Society, Wake Forest
University Health Sciences
Chairwoman Mikulski, Senators Enzi, Burr, Hagan, and other
distinguished members of the committee, thank you for the invitation to
be here today.
I am Dr. Kathi Kemper, Caryl Guth Chair for Complementary and
Integrative Medicine at Wake Forest University Baptist Medical Center,
founder of the American Academy of Pediatrics Section for Complementary
and Integrative Medicine, and the author of The Holistic Pediatrician.
This submitted testimony will briefly cover:
a definition of integrative health;
epidemiology of the use of complementary therapies (a
subset of integrative care) in pediatrics; and
review 10 principles of integrative care and how they
might inform health care reform.
I have also submitted the 12/08 publication in Pediatrics on the
use of CAM in pediatric populations and the White Paper on Research in
Integrative Medicine prepared for this week's Summit on Integrative
Medicine at the Institute of Medicine.
I. DEFINITION OF INTEGRATIVE HEALTH CARE
Integrative medicine is professional health care that is:
Evidence-based
Comprehensive
Systematic, including not only the individual, but also
the family, community and environment
Patient and family-focused, and
Emphasizes wellness, health promotion and disease/injury
prevention.
In short, integrative medicine is good medicine. Integrative
pediatrics is the practice of integrative medicine devoted to the care
of infants, children and adolescents. Among all medical specialties,
pediatrics is uniquely focused on health promotion and disease
prevention. Pediatrics takes a long-term view of outcomes, uses very
specific science-based strategies to enhance health behaviors and
address behavioral challenges, and works closely with community
institutions such as schools. Like family medicine, by definition, our
work encompasses of the health of the family as well as the individual.
Like pharmaceuticals, immunizations, surgery and other conventional
therapies, complementary and alternative therapies are subsets of the
therapeutic arsenal available to integrative clinicians to serve
patients' health needs. However, a collection of disparate therapies
does not constitute a true system of professional care any more than
our current collection of physicians, insurers, hospitals, governments,
non-profit groups, and for-profit pharmaceutical and device makers
constitutes a national health care system.
A functional system requires a shared vision; coordinated,
sustainable strategies to move toward that vision; consequences for
adherence to and deviations from strategically driven actions; data
collection to monitor the process and outcomes; feedback; and timely,
rational revisions to strategies, behaviors, monitoring systems and
consequences. The fact that Americans spend more than any other country
in the world on health and yet fail to achieve our national health
goals reinforces the need for a new, systematic approach informed by
integrative health care.
II. EPIDEMIOLOGY
The increasing numbers of Americans who use complementary and
alternative medical (CAM) therapies (a subset of integrative medicine)
supports the theory that conventional medicine is failing to meet
citizens' goals for health, and that a more comprehensive, patient-
centered approach that focuses on health outcomes rather than disease
management is desirable.
The December 2008 report from the American Academy of Pediatrics
and the December, 2008 report from the National Center for
Complementary and Alternative Medicine (NCCAM) and the National Center
for Health Statistics show that substantial numbers of American youth,
like adults, use CAM therapies. CAM use is lowest in healthy
populations. Excluding the use of prayer, folk remedies, multivitamins
and recommended supplements, approximately 12 percent of children and
youth receive CAM. The percentage in general pediatric clinics is
approximately 20 percent. Rates are 50 percent-70 percent in youth with
chronic conditions. A study published in 2008 from our pediatric
rheumatology clinic at Wake Forest Baptist Medical Center showed that
the rate of CAM use (92 percent) exceeded slightly the use of
conventional therapies (88 percent).
An American Academy of Pediatrics survey of 745 pediatricians,
published in 2004 showed that 87 percent of pediatricians had been
asked about CAM, 75 percent were concerned about potential risks or
side effects, 66 percent believed that CAM could enhance recovery or
relieve symptoms, yet only 20 percent discussed CAM with their
patients; 80 percent of pediatricians desired more training in these
areas.
As in adult studies, only about 40 percent of patients and families
who use CAM discuss it (or home or folk remedies) with their physician.
Despite the high rate of use of CAM therapies in pediatrics,
pediatrics has not been a priority population for NIH NCCAM research
funding (currently receiving less than 5 percent of such funding and
lacking a pediatric member on its Advisory Council). Conventional
training in the health professions has not included a requirement for
training in pediatric integrative medicine. Training in pediatrics for
other licensed health professionals, such as chiropractors, massage
therapists and acupuncturists has been variable.
The most commonly used CAM therapies in pediatrics are prayer,
dietary supplements, chiropractic and mind-body therapies.
Prayer is the most commonly used CAM therapy; various surveys show
that it is used for health purposes by 45 percent-85 percent of
pediatric patients/families. Substantial research shows that those who
pray and participate in religious communities such as churches are
healthier and engage in better health behaviors than those who do not.
The high prevalence of use; the associations with health and health
behaviors; the importance of prayer in American lives and communities;
the fact that physicians seldom ask about prayer despite patients'
desire for discussion on this topic; and the current lack of
coordination between medical institutions and faith communities
suggests several unmet needs regarding optimal integration of prayer,
faith and professional health care.
Dietary supplements, including use of vitamins, minerals, herbal
remedies, fish oils, probiotics and hormones, are the second most
commonly used group of CAM therapies in pediatrics. These products are
widely available over the counter and many are specifically marketed
for pediatric patients.
Despite their widespread availability and use, there has been
little research specifically in pediatrics on their safety and
effectiveness. It is likely that some (such as the already mainstream
use of folate to prevent neural tube defects and vitamin K to prevent
hemorrhagic disease of the newborn, and newer approaches such as
administering probiotics and enteric coated peppermint for GI patients)
are safe and effective, whereas others (such as St. John's wort to
treat attention deficit hyperactivity disorder or Echinacea to treat
pediatric cold symptoms) are not. Given the relatively small pediatric
market and the lack of patent incentives for natural products, it is
unlikely that the private marketplace will pursue such research.
Furthermore, current Federal regulations (e.g., DSHEA), which treat
these supplements more like food than medications, have left our
children and youth with little protection from variability in quality
and contamination with heavy metals (lead, cadmium), incorrect products
or pharmaceuticals. Currently, the situation for parents who purchase
dietary supplements for their children is best summarized by: ``buyer
beware.''
Even when dietary supplements ARE helpful (such as many families
for whom I care who report benefits from supplemental nutrients, omega-
3 fatty acids, herbs like ginger, and probiotics), families are left to
purchase them out of pocket because they are almost never covered by
insurance. This creates an economic disparity in access to effective
treatments. Furthermore, because natural products are usually less
expensive than prescription medications, relying on medications
(because they are covered by insurance) instead of less expensive
dietary supplements drives up health care costs.
Chiropractic and other manipulative therapies are the third most
commonly used CAM therapy in pediatrics, and the most common
professionally provided CAM therapy. Surveys suggest that up to 10
percent of chiropractic patients are under 21 years old; insurance
typically covers chiropractic care.
Despite this common use and cost, there has been little research on
the costs and benefits of chiropractic therapy for pediatric patients
in terms of its effectiveness for prevention or treatment. I am a big
fan of chiropractors, having received great benefit from chiropractic
treatment when I had a herniated disk. However, the data on success in
treating adults with low back pain simply cannot be extrapolated to
children with diverse health needs.
Many chiropractors market their services as primary care, yet
States do not typically license chiropractors to provide immunizations,
which represents a large lost opportunity to achieve public health
goals for universal immunization. The discussions about HIT have not
explicitly discussed chiropractors and other health professionals such
as naturopaths, acupuncturists or massage therapists, yet they are an
important and growing part of patient-centered and patient-driven care.
Chiropractic training in pediatrics is limited, and communication
and coordination between chiropractors and medical doctors is poor.
This may result in delays in seeking care, redundant X-rays or other
diagnostic tests or conflicting professional recommendations.
Massage therapy is widely offered in U.S. hospitals to newborns,
and a substantial body of research supports the use of massage to
promote health in diverse pediatric conditions. However, Medicaid and
other insurers rarely cover massage services. This means that access to
this helpful service is limited to those who can afford to pay out-of-
pocket, resulting in significant disparities in access to therapeutic
massage.
Mind-Body Therapies such as progressive relaxation, deep breathing,
meditation, yoga, biofeedback and guided imagery are the fourth most
common category of CAM therapies used by families and youth. Most
often, families use these practices without professional guidance due
to shortages of pediatric mental health professionals and uneven
insurance coverage for these services and products (again, resulting in
disparities in access to effective services).
Mind-body therapies are useful in managing a variety of pediatric
symptoms: pain, headaches, anxiety, insomnia, inattention, impulsivity,
and stress-related symptoms. Unlike medications, which frequently have
side effects and contra-indications (but which are nearly universally
covered by insurance), mind-body therapies have side benefits. For
example, learning to practice a stress management technique to reduce
the frequency of migraine headaches can help a student manage test
anxiety; an evaluation of the HeartMath emotional self-management
program (which uses biofeedback among other techniques) in California
schools showed a significant improvement in test anxiety and test
scores.
Unlike medications, whose benefits typically end when someone stops
taking it, the benefits of learning a skill endure for months and years
after the initial training.
Many mental health disorders, such as anxiety, depression and
substance abuse have their onset in pediatric ages. Given the alarming
rates of mental, emotional and behavioral disorders that first appear
during childhood and adolescence (costing the United States an
estimated $247 billion according to a report from the Institute of
Medicine), there is an urgent need to address the gap between what is
known about preventing these disorders and what is actually done.
Providing access to mind-body therapies that help youth learn to manage
stress more skillfully than using tobacco, alcohol or drugs represents
one such strategy.
III. PRINCIPLES OF INTEGRATIVE HEALTHCARE
Integrative Healthcare includes several principles that are vital
to cost-effective, equitable, efficient, timely, safe and sustainable
health care for America's youth. They are consistent with much of what
has been discussed at earlier HELP hearings this year on related
topics. These principles are outlined below with figures following the
text.
Principles alone are insufficient for forming policy; substantial
additional research is needed to determine how best to translate what
is known into an effective, coordinated system of health promotion
across the tiers of physical environment, social environment, personal
health behaviors, community care, primary care and specialist care.
Please see the supplementary white paper on Research Priorities in
integrative Medicine, which was prepared for this week's Institute of
Medicine Summit on Integrative Medicine.
1. 1st Principle. Integrative healthcare is holistic, systematic
and ecological. This means that it is concerned with health of the
body, mind, emotions, spirit and relationships in the context of
family, culture, community, and environment. Health in one aspect of
one's being is intricately bound up with the others. Changes in one
aspect of an individual or community affect others. Good physical and
mental health requires healthy habits in a healthy habitat. (Figure 1)
These should be the primary focus of our funding and our policy.
Professional health care is also important, but it is not a replacement
for the fundamentals of healthy habitats and habits.
a. Integrative health care endorses the public health principles
eloquently articulated by Dr. Fielding in his testimony at the hearing
on 1/22/09. An unhealthy physical habitat--polluted water and air,
contaminated foods, mercury-laden fish, lead in toys, a rapidly
changing climate, school vending machines dispensing unhealthy foods
and beverages, and lack of access to parks and recreation, safe
neighborhoods, bike paths, recess, daylighting in schools--and
unhealthy social habitats--poverty, discrimination, poor quality
schools, violence, child abuse, media that portray smoking, unsafe
sexual practices and misuse of alcohol and other drugs and that markets
unhealthy products and promotes consumerism to children--impair our
children's health. Social policies regarding agriculture,
transportation, urban planning, foreign relations, education, energy,
environment, and communications have profound impacts on health. Health
should be an explicit outcome when weighing the costs and benefits of
Federal policies even in these ``non-health'' related fields.
b. Building on the foundation of healthy habitats are healthy
habits. Five fundamentals of healthy habits include: optimal activity
and sleep; nutrition; making healthy choices about personal
environmental exposures; skillfully managing stress; and communicating
effectively (See Figure 2). Because healthy habits are critical to good
health, it is important for us to create social policies that make it
easier to act wisely.\1\ We also need timely, relevant information and
systems to make it easy to make health decisions. Most health habits
are established in childhood; promoting healthy habits between the ages
of 10-24 has an especially high return on investment. Although much of
the discussion has focused on nutrition and exercise, there is abundant
evidence that children and youth desperately need to develop skills in
managing stress and communicating effectively and productively in order
to meet health and other needs.
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\1\ For example, behaviors are often sensitive to price. Increasing
the price of tobacco reduces smoking rates in teenagers. Research is
needed to determine the impact of changes in the price, information
(nutritional labeling) or additional taxes on unhealthy foods (e.g.,
taxing drive-through meals more than walk-in service) on obesity and
other health outcomes. The price of many medical interventions (tests,
therapies) are often not apparent to patients until the bill arrives;
even many professionals do not know what tests and procedures cost;
providing timely access to price information affects ordering and
prescribing behavior. Similar information and incentives about using
medical diagnostic tests, procedures and therapies may have dramatic
impact on health costs and outcomes, and requires systematic research.
c. Just as healthy habits do not exist in a vacuum, professional
health care occurs within the context of self-care and family care.
Patients and families with chronic conditions have often already sought
information from friends, family, teachers, colleagues, and other
health professionals, books, magazines and the Internet. Clinicians
need to be proactive and ask what patients are already doing for their
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health and how well it is working.
Clinicians need to be skillful in assisting patients to make
behavior changes consistent with their health goals, based on the
science of effective behavior change, such as the skills of
motivational interviewing (assessing goals, confidence, barriers,
resources, exploring ambivalence and helping to set specific,
measurable actions with clear consequences and plans for evaluation and
reassessment). Clinicians also need to be able to advise patients and
families about the best sources of evidence-based information on the
internet and to steer them away from ``snake oil salesmen'' and those
whose interests in profit exceed their dedication to patients' health.
2. Second principle. ``First, do no harm,'' means that when
additional therapies (beyond healthy lifestyle) are needed to achieve
an individual's health goals, priority should be given to those that
are safe. Safe means not only low in side effects, but also low in
direct and opportunity costs, and least harmful to the values,
integrity, self-respect, autonomy and cultural identity of the child
and family, as well as the sustainability of resources for future
generations. Natural therapies and healthy behaviors are typically
safer than pharmaceutical and surgical approaches, but existing
financial incentives have limited their use in professional practice.
3. Third Principle. Comprehensive, culturally competent care. The
spectrum of therapeutic options might be considered in four categories:
(a) Healthy lifestyle habits as described above;
(b) Biochemical therapies such as medications, but also including
dietary supplements such as vitamins and minerals to correct
deficiencies or address unique needs due to genetic, medical,
behavioral or environmental factors;
(c) Biomechanical therapies such as surgery, and also massage,
bodywork and manipulative therapies; and
(d) Bio-energetic or biofield therapies such as radiation therapy,
electromagnetic therapies, acupuncture, Healing Touch, Therapeutic
Touch and Reiki, prayer and homeopathy (Figure 3).
Integrative health care recognizes the importance of indigenous
healing systems that employ multiple types of therapies such as
Ayurvedic medicine, Traditional Chinese Medicine, Native American
medicine, the traditional practices of Hawaiian healers, and folk
healing traditions.
4. Fourth Principle. Integrative pediatric health care emphasizes
health promotion, wellness and prevention. This means that it is
explicitly focused on achieving positive goals, not simply the absence
of disease. While some cynics have described a healthy person as ``one
who has not been sufficiently evaluated,'' integrative practitioners
focus on physical, emotional, mental, spiritual and social health
(Figure 4). A clear focus on health outcomes and their modifiable
environmental and social determinants (not just the process of care) is
necessary.
Many academic health centers (AHCs), including pediatric hospitals,
derive much of their clinical revenue from providing high tech care for
the sickest patients. For example, pediatric departments are frequently
financially dependent, in part, on income from clinical care of
premature infants. They lose money when prematurity rates are reduced
(successful achievement of a public health goal lowers revenues for
tertiary care institutions). This kind of unintended perverse
incentives does not contribute to the promotion of our national health
goals for children and youth.
5. Integrative health care is patient-centered, service-oriented
and committed to empowering individuals and families. We appreciate the
tremendous growth of scientific knowledge over the past century, yet we
are humbled by the amount still to be learned, and we are in awe of the
power of the innate healing ability.\2\ We also recognize that the
patient and family are the experts on their own lives. This means that
it is the individual patient or client's goals, needs and values that
frame decisions. Rather than looking at patients' compliance or
adherence, the focus is on how well current strategies, clinicians,
therapies and systems of care meet the patients' goals. Integrative
care requires open dialogue, collaboration, reflection, analysis, and
revision. The process recognizes that patients and families may hold
multiple goals, conditions, values, explanatory models, and
expectations simultaneously. These factors may change over time,
requiring flexibility. Integrative medicine also recognizes that some
therapies target specific symptoms or cure that then result in improved
overall sense of well-being; other therapies target general well-being
which may reduce the risk of several illnesses.
---------------------------------------------------------------------------
\2\ As every surgeon knows, we can put the pieces together, but the
actual healing lies in the innate wisdom of the patient's body.
---------------------------------------------------------------------------
Because individualized, patient-centered care requires substantial
information and dialogue, attention to efficiency, flexibility and
innovation are important. Current models are time consuming and poorly
reimbursed using conventional models. Focusing reimbursement on the
most highly paid professionals (physicians) to provide care that could
be equally effective at lower cost (using coaches, nurses, educators,
nutritionists, fitness coaches, PAs, nurse practitioners, interactive
Web sites, and others) is costly, inefficient, and unnecessary.
6. Integrative health care emphasizes integrity, open-mindedness
and fairness. This means that integrative clinicians aspire to live
healthfully and be role models of healthy lifestyles, promoting healing
environments, and advocating for life-sustaining clean air, water, and
other systems essential for optimal health. We advocate for health care
that promotes a healthy planet (green health care). There is no
national standard for training health professionals that focuses on
personal health behavior. Nor are there national standards for health
care institutions to become less polluting or ``greener.''
7. Integrative health care is informed by scientific evidence and
human experience. We are deeply grateful for, rely on and support the
vast and growing body of scientific understanding and evidence. We also
recognize the limitations of extrapolating results of population
studies to individuals who may differ substantially from those involved
in clinical trials. This means that pay for performance is important,
but not sufficient. We must pay for outcomes. A broader scientific
agenda is needed to better understand how to translate knowledge into
patient-centered health promotion effectively, efficiently, equitably,
safely and sustainably.
8. Integrative care is multidisciplinary. Learning to work with
professionals of different backgrounds and skills requires enhanced
communication and teamwork skills. Expanding the notion of
multidisciplinary teams focuses on the importance of communication and
teamwork skills. These skills should be developed throughout training
in the health professions, when diverse clinicians could learn together
a common core of skills such as effective counseling techniques,
working together in teams, strategies for enhancing quality
improvement, and working with community institutions, businesses, and
public health systems to implement, evaluate and continuously improve
diverse approaches to health promotion.
9. Integrative health care is practical as well as principled.
Being practical means that we do what works for the patient, balancing
effectiveness with risks (Figure 5). If antibiotics do not cure the
common cold, they should not be prescribed, nor covered by insurance
(for that use). If massage, acupuncture or biofeedback relieve symptoms
and improve health outcomes safely and effectively for children and
families, they should be accessible. If a non-physician acupuncturist
is as effective as a physician acupuncturist, there should be no
disparities in reimbursement for their services. If meditation classes
help adolescents reduce stress, lower blood pressure and relieve pain,
shouldn't there be access to those services as well as to medications?
10. Integrative health care recognizes that the opportunities of
the internet era also presents challenges to the conventional model of
care of State system of credentialing health professionals. There are
no national standards for licensing all health professionals, including
acupuncturists (now licensed in over 40 States), massage therapists
(licensed in some places by municipality and others on a statewide
basis), and naturopathic physicians (licensed in just over a dozen
States). National systems are needed to ensure safe, responsible
practices and access to cost-effective services across State lines (via
internet counseling, coaching, and consulting).
IV. SUMMARY OF RECOMMENDATIONS
Overall Federal health policies: Aim for alignment and integration
between ``non-health'' policies, public health, personal habits and
professional care to promote optimal pediatric health.
A. Research
1. Increase NIH NCCAM funding for pediatric research, particularly
for therapies of potentially greater risk and common use such as
dietary supplements; those that are commonly used and generate
substantial costs, such as professional chiropractic care; and those of
potentially great value and safety across the lifespan such as mind/
body stress and symptom management practices.
2. Ensure that there is pediatric representation on the NIH NCCAM
Advisory Council.
3. Conduct research on the cost-effectiveness of explicitly
addressing health promotion in the context of churches and other
religious, spiritual and faith communities.
4. Support research on the long-term, comparative costs and
benefits of different therapies and strategies (including public
policies and novel delivery models) to achieve health goals. Include
opportunity costs, and costs to self-esteem, cultural identity,
integrity and autonomy. Include citizen groups, bioethicists, and
economists as well as diverse health professionals in planning such
research.
5. Expand the scientific agenda to better understand how to improve
systems of care and translate knowledge into practice.
6. Develop new scientific models to better extrapolate from
research conducted on narrow populations to diverse, unique individual
patients with multiple, changing health goals and needs. This is
particularly important for pediatric patients whose development results
in ongoing changes in needs.
B. Professional Training
1. Foster training for pediatric health professionals to:
discuss CAM use with patients and families;
ask about use of folk remedies and spiritual and
religious beliefs and practices related to health;
provide evidence-based information about CAM
therapies to ensure safe practices in these vulnerable
populations;
record use of natural therapies in patients' health
records;
report suspected adverse effects to FDA Medwatch and
other appropriate agencies; and
Communicate with and coordinate care between
clinicians, churches, schools, and other community
institutions.
2. Increase the number of health professionals who can provide
mind-body therapies, and coach children and youth to successful stress
management practices and positive communication skills.
3. Support professional education to develop expertise in
effective, sustainable changes in health behaviors, such as
motivational interviewing.
4. Ensure that training for pediatric health professionals includes
common core training in healthy lifestyles (including stress management
and skillful communication to build interpersonal relationships) and
natural therapies. Professional training should foster early and
ongoing awareness and practice of healthy lifestyles.
5. Ensure that training for health professionals develops an
awareness of and respect for the diverse therapies and cultural
traditions that affect health.
6. Provide appropriate incentives and penalties for professional
training programs to achieve these goals.
C. Community Information and Education
1. Ensure that families have access to the best current clinical
evidence regarding the safety and effectiveness of natural health
products commonly used by children and youth.
2. Promote evidence-based health education and activities in
schools.
3. Provide health education, coaching and support using cost-
effective strategies, e.g., peer support, community nurses, health
coaches, nutritionists, fitness counselors, meditation teachers, or
counselors.
D. Safety and Regulations
1. Review and consider revising FDA regulations concerning dietary
supplements, particularly those marketed to children, to ensure that
families have access to safe, high quality, reliable products.
2. Review and consider regulations to allow chiropractors and other
health professionals commonly seen by pediatric patients to provide
immunizations.
3. Develop active surveillance systems to detect and respond to
adverse effects from therapies for children and youth.
4. Review and evaluate professional licensing across all 50 States
and devise models of reimbursement to cover efficient, safe,
accessible, high quality, timely inter-state, on-line health services,
consulting counseling or coaching.
E. Access to, Provision of and Reimbursement for Clinical Integrative
Services
1. When evidence suggests that natural therapies, services and
products are as or more safe and effective as other therapies for
promoting health and decreasing symptoms in infants, children and
adolescents, encourage insurers to cover these services.
2. Incentivize professional integrative health care that provides
adequate counseling and coaching to promote healthy habits for children
and youth and provides health care services that offer safe and
effective patient-centered care of good value, minimizing disparities
to access, particularly for vulnerable populations such as infants,
children and adolescents.
3. Encourage healthy lifestyles among health professionals to
provide effective role models.
4. Incentivize productive, timely communication and coordination
among chiropractors, acupuncturists, psychologists, massage therapists,
naturopathic physicians and other licensed health professionals who
care for children and youth.
5. Develop, implement and evaluate potentially more cost-effective
models for delivering care, such as peer support and counseling, public
health nurses, care in groups, by telephone and webinars,
videoconferences and teleconferences as well as in individual visits.
6. Develop new models that promote continued expansion and
dissemination of new knowledge and understanding through AHCs without
fostering financial dependence on expensive, disease management based
on generating RVUs (i.e., change pay for visits to pay for performance
and outcomes). Make it financially worthwhile for AHCs to focus on
health promotion, and work with the public health sector to achieve
population health goals.
F. Federal Policies Which Are Not Directly Health-Related
1. Systematically review and, as needed, revise Federal policies
that directly or indirectly affect the health of children and youth.
These include (but are not limited to) transportation, agriculture,
energy, education, environment, commerce, and communication.
2. Support Federal policies that promote healthy physical, social
and psychological environments for children and youth such as expanding
the Family Medical Leave Act.
3. Incentivize ``green'' health care for large institutions
including health facilities. This means not only reducing electricity
and water usage, increasing recycling and using green cleaning
practices; it also means promoting efficient transportation and
reimbursing for professional care provided by telephone, internet or
webinar to minimize generation of green house gases involved in travel.
Using new technology to provide professional care would also enhance
access to those in rural areas and those who lack transportation.
G. Other
1. Incentivize citizens' personal habits that are health promoting
such as breastfeeding; provide information to allow families to make
healthy choices for their children (such as nutrition information about
restaurant meals for children).
2. Develop information technology (already discussed at length in
these hearings) to more efficiently gather and process information
(e.g., Dr. Kelly Kelleher has demonstrated that mothers can enter data,
history, habits, etc., into on-line health risk appraisal forms for
automated scoring and analysis prior to seeing their pediatrician. This
simple IT solution effectively enhances clinicians' recognition of and
response to families' concerns about behavioral health issues).
The system we have is perfectly designed to achieve the results we
are now experiencing. If we want different results, we need to change
the system. We need to start with a clear vision of a healthy nation
and plan an integrated system, including alignment with other national
goals, to develop sensible, sustainable strategies. Just as a health
behavior such as exercise is health promoting and has benefits on
numerous outcomes (e.g., weight, heart disease, mental health), sound
policies should have diverse benefits. Healthy people are productive
people who are best able to solve our national and global problems.
I believe the 10 principles of pediatric integrative health care--
focusing on health promotion and disease/injury prevention through
patient-centered, comprehensive, evidence-based policies that promote a
healthy environment, personal health habits, and professional care--can
help us achieve national health goals effectively, efficiently,
equitably, safely and sustainably.
Thank you for the opportunity to present this testimony.
Prepared Statement of Simon Mills, M.A., FNIMH, MCPP
I have been active in the field of ``integrated'' health care for
over 30 years. I currently lead a U.K. government grant ``Integrated
Self-care in Family Practice'' which is developing ways to support
patients' self-reliance in their health care and recently set up the
first Masters program in Integrated Health at a medical school in the
U.K. My bio has also been submitted.
This submission reflects the different cultures within U.K. and
Europe and the role that integrated health has played against the
backdrop of change in healthcare provision. Health services in the U.K.
and Europe are often described as ``socialized.'' It is indeed the case
that European Member States all provide relatively more central funds
for health care. However all are also looking for ways to spend less on
health care and integrated health is seen as a way in which the public
may take a bigger share of costs as well as responsibilities for their
health.
Most of the following relates to the United Kingdom where the term
``integrated health'' has more currency. It is generally taken to mean
the integration of complementary and alternative medicine (CAM) with
the mainstream. It should be noted however that health care in much of
continental Europe has been relatively integrated in this way for
decades. A German or French physician will regularly prescribe
``phytomedicines'' (aka ``herbal medicinal products''). Medicines like
ginkgo, hawthorn, valerian, horse chestnut, St. John's wort, saw
palmetto are routinely prescribed for major clinical conditions like
dementia, heart disease, insomnia, venous disease, depression and
prostate disease (respectively) in preference to synthetic medicines.
Each of the products concerned will be manufactured to pharmaceutical
standards so are reliable and well-documented. (I refer to my
experience as Secretary of ESCOP, a network of researchers and
practitioners across Europe that publishes formal drug dossiers for the
Herbal Medicinal Products Committee of the European Medicines Agency--
www.escop.com.) In most cases such prescription is no longer reimbursed
from central funds so the continuing use of these medicines is directly
in response to self-financed public demand. All European pharmacies
will also have large and prominent stocks of herbal pharmaceuticals
which are entirely in the self-medication sector. There are also many
homoeopathic treatments available from pharmacies, and physicians and
other European health professionals may be associated with the
provision of therapies like aromatherapy, hydrotherapy, naturopathy,
and ``Anthroposophic'' medicine. That such provision is available
clearly reflects a different cultural expectation among the population.
In the U.K. integrated health has emerged out of the flowering of
alternative and then complementary medicine from the 1970s. Unlike most
of Europe the U.K. maintained common law principles in the provision of
health care so that it is possible to practise most CAM therapies
without a licence (the extremely low professional liability insurance
cover for most CAM practitioners--generally less than U.S. $200 per
annum--suggests that this has not been a public hazard). In this benign
climate there has been extensive professional development in these
therapies and two, osteopathy and chiropractice were State licensed in
the 1990s and acupuncture and herbal practice are likely to achieve the
same status very soon. However none of these therapies has, or is
likely to be, provided through the State-funded National Health
Service.
There is however evidence that the use of CAM may reduce central
costs. In a recent government pilot study in Northern Ireland,\1\ 713
patients with a range of ages and demographic backgrounds and either
physical or mental health conditions were referred to various CAM
therapies via nine family medicine practices.
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\1\ http://www.dhsspsni.gov.uk/index/hss/complementary-alternative-
medicine.htm.
around 80 percent of patients reported an improvement in
their physical or mental health;
in 65 percent of patient cases, family physicians
documented a health improvement;
94 percent of patients said they would recommend CAM to
another patient with their condition;
half of family physicians reported prescribing less
medication and all reported that patients had indicated to them that
they needed less; and
65 percent of family physicians reported seeing the
patient less following the CAM referral.
Such data, supported in other studies, may offset criticisms that
the relatively poor evidence base for CAM therapies means that
integration with mainstream medicine is not appropriate.
There is no doubt that the public has taken to CAM therapies and
that individuals are willing to pay for them outside free National
Health Service provision. Various surveys suggest that up to half the
population has tried a CAM treatment and that around 20 percent are
regular users.
A leading supporter for integration has been HRH The Prince of
Wales who as heir to the Throne has significant influence on public
debate. He has set up the Prince's Foundation for Integrated Health
whose Web site (fih.org.uk) is a major resource on this subject. In its
definition the Foundation highlights several key features of the
phenomenon.
WHAT IS INTEGRATED HEALTH?
Responsibility for our health isn't something we can simply
delegate to doctors and medicine. Most aspects of health are a
reflection of the way we live our whole lives.
But once somebody is ill, treating their problem with an integrated
approach means bringing together mainstream medical science with the
best of other traditions.
Integrated health is a response to the changing patterns of disease
in the early 21st century.
The patients now taking up around 80 percent of the time and
resources of the health service are those experiencing a slow slide
into chronic conditions--such as allergies, back pain, stress or heart
disease. Unaddressed, these illnesses can accumulate into crippling
conditions.
We know too that empowerment is good for patients. . . . when
patients are equal partners in the management of their own health, it
can actually have an affect on their clinical outcomes.
Of course, even the most fortunate person will in the end
experience the effects of degeneration, old age and approaching death.
So finally, integrated health looks beyond physical health to the
factors that can give us solace, courage and dignity in difficult
times.
This approach presents challenges for the general public and
healthcare practitioners. Patients cannot just wait passively for
others to find solutions. Doctors have to listen to their patients and
seek more creative solutions.
To conclude integrated health in the U.K. is seen as an approach
that may shift the locus of control from the physician to the patient,
and one that the public is willing to pay for. These are reasons to
commend it for serious consideration by
policymakers in the U.S.A.
[Whereupon, at 4:15 p.m., the hearing was adjourned.]