[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


  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
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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.

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Acknowledgement: A general resource for information on the CAM 
professions was the Clinicians and Educators Desk Reference on the 
Licensed Complementary and Alternative Health Care Professions,'' 
edited John Weeks and Elizabeth A. Goldblatt, Ph.D., MPA/HA in 
collaboration with the American Massage Therapy Association Council of 
Schools, Association of Chiropractic Colleges, Association of 
Accredited Naturopathic Medical Colleges, Council of Colleges of 
Acupuncture and Oriental Medicine, and the Midwifery Accreditation 
Education Council. This resource book will be published by the Academic 
Consortium for Complementary & Alternative Health Care in 2009.

    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\
---------------------------------------------------------------------------
    \1\ Centers for Disease Control, http://www.cdc.gov/nccdphp/dnpa/
Obesity/trend/maps/index
.htm.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \6\ Health Management Research Center. (2008) Cost Benefit Analysis 
and Report 2008. University of Michigan, Ann Arbor, MI.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \24\ Testimony of Ron Z. Goetzel, Ph.D., before the House Armed 
Services Committee Subcommittee on Military Personnel, March 12, 2008.

---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \26\ Health & Vitality Ink Communications. The Case for Health 
Promotion Programs. 2002.



---------------------------------------------------------------------------
      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\
---------------------------------------------------------------------------
    \27\ Health Management Research Center. (2008) Cost Benefit 
Analysis and Report 2008. University of Michigan, Ann Arbor, MI.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    One meta-review of 56 published studies of workplace health 
promotion programs shows \29\:
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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.

                               REFERENCES

    1. Kroenke, K. & Mangelsdorff, A.D. Common Symptoms in Ambulatory 
Care: Incidence, Evaluation, Therapy, and Outcome. Am J Med 86, 262-266 
(1989).
    2. Cannon, W. Emergency Function of the Adrenal Medulla in Pain and 
the Major Emotions. Am J Physiol 33, 356 (1914).
    3. Cannon, W. Bodily Changes in Pain, Hunger, Fear and Rage; an 
Account of Recent Research Into the Function of Emotional Excitement. 
(Appleton and company, New York, 1915).
    4. Selye, H. The Stress of Life (McGraw-Hill, New York, 1956).
    5. McEwen, B.S. Stress, Adaptation, and Disease. Allostasis and 
Allostatic Load. Ann NY Acad Sci 840, 33-44 (1998).
    6. Astin, J.A., Shapiro, S.L., Eisenberg, D.M. & Forys, K.L. Mind-
Body Medicine: State of the Science, Implications for Practice. J Am 
Board Fam Pract 16, 131-147 (2003).
    7. Beary, J.F. & Benson, H. A Simple Psychophysiologic Technique 
Which Elicits the Hypometabolic Changes of the Relaxation Response. 
Psychosom Med 36, 115-120 (1974).
    8. Wallace, R.K., Benson, H. & Wilson, A.F. A Wakeful Hypometabolic 
Physiologic State. Am J Physiol 221, 795-799 (1971).
    9. Benson, H. The Relaxation Response. (William Morrow, New York, 
1975).
    10. Benson, H., Dryer, T. & Hartley, L.H. Decreased VO2 Consumption 
During Exercise With Elicitation of the Relaxation Response. J Human 
Stress 4, 38-42 (1978).
    11. Dusek, J.A., et al. Association Between Oxygen Consumption and 
Nitric Oxide Production During the Relaxation Response. Med Sci Monit 
12, CR1-10 (2006).
    12. Benson, H., Steinert, R.F., Greenwood, M.M., Klemchuk, H.M. & 
Peterson, N.H. Continuous Measurement of O2 consumption and CO2 
elimination during a wakeful hypometabolic state. J Human Stress 1, 37-
44 (1975).
    13. Hoffman, J.W., et al. Reduced Sympathetic Nervous System 
Responsivity Associated With the Relaxation Response. Science 215, 190-
192 (1982).
    14. Lazar, S.W., et al. Functional Brain Mapping of the Relaxation 
Response and Meditation. Neuroreport 11, 1581-1585 (2000).
    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.
---------------------------------------------------------------------------
    * 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.

                               References

    1. Amler R, Dull, HB (ed). Closing the gap: The burden of 
unnecessary illness. American Journal of Preventive Medicine. 
1987;3(Sep 5).
    2. Department of Health and Human Services. Healthy People 2000: 
National Health Promotion and Disease Prevention Objectives. Pub. No. 
(PHS) 91-50213, Washington, DC: U.S. Government Printing Office, 1991.
    2. McGinnis J, Foege WH. Actual causes of death in the United 
States. Journal of the American Medical Association. 1993;270:2207-
2212.
    3. Mokdad A, Marks JS, Stroup DF, Gerberding JL. Actual causes of 
death in the United States. Journal of the American Medical 
Association. 2004;291:1238-1245.
    4. Ogden CL, Fryar CD, Carroll MD, and Flegal KM Mean Body Weight, 
Height, and Body Mass Index, United States 1960-2002. Atlanta, GA: 
Centers for Disease Control and Prevention: Advance Data from Vital and 
Health Statistics. Publication No. 347. October 27, 2004.
    5. Finkelstein E, Fiebelkorn C, Wang G. The costs of obesity among 
full-time employees. American Journal of Health Promotion. 2005;20:45-
51.
    6. Anderson DR, Whitmer RW, Goetzel RZ, Ozminkowski RJ, Wasserman 
J, Serxner S, HERO Research Committee. The relationship between 
modifiable health risks and group-level health care expenditures. 
American Journal of Health Promotion. 2000;15:45-52.
    7. Goetzel RZ, Anderson DR, Whitmer RW, Ozminkowski RJ, Dunn RL, 
Wasserman J, HERO Research Committee. The relationship between 
modifiable health risks and health care expenditures. Journal of 
Occupational and Environmental Medicine. 1998;40:843-854.
    8. The Ultimate 20th Century Cost Benefit Analysis and Report. The 
University of Michigan; 2000.
    9. Heaney CA, Goetzel RZ. A review of health-related outcomes of 
multi-component worksite health promotion programs. American Journal of 
Health Promotion. 1997;11:290-308.
    10. Goetzel RZ, Ozminkowski RJ. (2008) The Health and Cost Benefits 
of Work Site Health-Promotion Programs. Annual Review of Public Health. 
Online Version: 2008 Jan. 3. Print: Volume 29, Apr 2008.
    11. Task Force on Community Preventive Services. 2007. Proceedings 
of the Task Force Meeting: Worksite Reviews. Atlanta, GA: Centers for 
Disease Control and Prevention.
    12. Goetzel RZ, Juday TR, Ozminkowski RJ. (1999). What's the ROI?--
A systematic review of return on investment (ROI) studies of corporate 
health and productivity management initiatives. Association for 
Worksite Health Promotion. Summer: 12-21.
    13. U.S. Department of Health and Human Services. Prevention makes 
common ``cents.'' http://aspe.hhs.gov/health/prevention/prevention.pdf, 
September 2003.
    14. Pelletier KR. A review and analysis of the health and cost-
effective outcome studies of comprehensive health promotion and disease 
prevention programs at the worksite: 1993-1995 update. American Journal 
of Health Promotion. 1996;10:380-388.
    15. Breslow L, Fielding J, Herman AA., et al. Worksite health 
promotion: its evolution and the Johnson and Johnson experience. 
Preventive Medicine. 1994;9:13-21.
    16. Bly J, Jones R, Richardson J. Impact of worksite health 
promotion on health care costs and utilization: Evaluation of the 
Johnson and Johnson LIVE FOR LIFE program. The Journal of the American 
Medical Association. 1986;256:3236-3240.
    17. Ozminkowski RJ, Dunn RL, Goetzel RZ, Cantor R, Murnane J, 
Harrison M. ``A return on investment evaluation of the Citibank, N.A. 
Health Management Program.'' American Journal of Health Promotion. 
1999;14:31-43.
    18. Bertera R. The effects of worksite health promotion on 
absenteeism and employee costs in a large industrial population. 
American Journal of Public Health, 1990;80:1101-1105.
    19. Leigh J, Richardson N, Beck R., et al. Randomized controlled 
trial of a retiree health promotion program: the Bank of America Study. 
Archives of Internal Medicine. 1992;152:1201-1206.
    20. Fries J, Bloch D, Harrington H, Richardson N, Beck R. Two-year 
results of a randomized controlled trial of a health promotion program 
in a retiree population: The Bank of America Study. The American 
Journal of Medicine. 1993;94:455-462.
    21. Baun W, Bernacki E, Tsai S. A preliminary investigation: 
Effects of a corporate fitness program on absenteeism and health care 
costs. Journal of Occupational Medicine. 1986;28:18-22.
    22. Knight K, Goetzel R, Fielding J., et al. An evaluation of Duke 
University's LIVE FOR LIFE health promotion program on changes in 
worker absenteeism. Journal of Occupational Medicine, 1994; 36: 533-
536.
    23. Fries J, Harrington H, Edwards R, Kent L, Richardson N. 
Randomized controlled trial of cost reductions from a health education 
program: The California Public Employees Retirement System (PERS) 
study. American Journal of Health Promotion, 1994; 8: 216-223.
    24. Goetzel R, Jacobsen B, Aldana S, Vardell K, Yee L. Health care 
costs of worksite health promotion participants and non-participants. 
Journal of Occupational and Environmental Medicine, 1998; 40: 341-346.
    25. Goetzel R, Dunn R, Ozminkowski R, Satin K, Whitehead D, Cahill 
K. Differences between descriptive and multivariate estimates of the 
impact of Chevron Corporation's Health Quest program on medical 
expenditures. Journal of Occupational and Environmental Medicine, 1998; 
40: 538-545.
    26. Naydeck BL, Pearson J, Ozminkowski RJ, Day B, Goetzel RZ. 
(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.
---------------------------------------------------------------------------
    \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 
---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
    \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.]

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