Working with Integrative Health Care Providers

The integrative medicine paradigm holds great promise in solving many of the problems that plague American health care. With its focus on prevention, patient empowerment, interpersonal relations, and relatively low-cost therapies that positively affect multiple organ systems with few adverse effects, the integrative approach is exactly what we need to remedy a system that all-too-often fails patients, frustrates doctors and fosters financial ruin.

There are signs that mainstream medicine is moving in this direction. Nearly all of the nation’s medical schools now have coursework in Complementary and Alternative Medicine (CAM); most major medical centers have affiliated holistic health clinics. The Bravewell Collaborative, a philanthropy founded by Christy and John Mack of Morgan Stanley and Penny and Bill George of Medtronic, has funded clinical research as well as health systems development at integrative medical centers across the nation.

Continuing medical education programs on nutrition and other aspects of natural medicine are blossoming. The growth of groups such as the Institute of Functional Medicine, American College for Advancement in Medicine and others attest to this, as do the emergence of the American Board of Holistic Medicine and the American Clinical Board of Nutrition, offering doctors formal certification in holistic disciplines. In an historic first, the American Holistic Medical Association (representing holistically minded M.D.s and D.O.s) and the American Association of Naturopathic Physicians are holding a joint annual meeting.

Even the American Academy of Family Physicians, a historically conservative medical organization, has stepped up its education efforts; last year’s annual conference featured several well-attended talks on nutrition, functional medicine and stress management. Many practitioner-channel nutraceutical companies were there among the pharma giants on the exhibit floor, something one did not see 10 years ago.

Health practitioner supplement sales are growing, according to data published in Nutrition Business Journal. From 1997 to 2004 (the last year for which we have data), there was a 100-fold increase in practitioner channel sales, from $720 million to $1.44 billion. That figure continues to grow at about 10 percent per year. The biggest growth is among M.D.s, nurses, and massage therapists. Supplement sales by M.D.s and nurses increased by 874 percent, from $15.5 million in 1997 to $151 million in 2004. But the biggest growth was among massage therapists, who sold $72.6 million worth of supplements in 2004, up from just $6.6 million in 1997.

Data from a proprietary market analysis commissioned by a major pharmaceutical company considering entry into practitioner nutrition underscores a major attitudinal shift among primary care providers. The survey involved more than 1,000 primary care doctors nationwide. While about 20 percent still hold “old school” negative views toward nutrition and supplements, an equal number said they were using nutrition-based strategies—including supplements—as first-line approaches.

Twenty-three percent of the doctors said they were generally in favor of lifestyle and diet changes, though they did not usually recommend dietary supplements; 14 percent said they were skeptical, but willing to consider data showing nutraceutical efficacy. The Natural Marketing Institute (NMI) recently reported 19 percent of consumers surveyed said they purchased natural products from a health care practitioner in the past three months. For consumers over 65, the figure was 26 percent.

These positive changes are occurring against a background of extreme unrest in health care. In primary care, many patients are fighting for survival. Insurance reimbursement has declined steadily and many practitioners are working harder and faster yet making less. Administrative overhead and malpractice premiums soar, and we’re confronted by the bewildering complexity of insurance coding and practice management challenges that medical training didn’t cover. According to the Medical Group Management Association’s 2006 Cost Survey for Multispecialty Practices, multispecialty group practices in the United States are paying a median of 5.7 administrative staffers for every physician! That’s a lot of payroll overhead.

The number of doctors taking bank loans to keep their practices afloat has hit an all-time high, as has the number of doctors defaulting. Not surprisingly, fewer new med school graduates are going into primary care; many young physicians are re-thinking their careers altogether. Primary care has been particularly hard-hit but these trends affect most specialties, too.

There are many factors contributing to the mess. A big one is that insurance reimbursement preferentially rewards invasive procedures and late-stage disease care, over preventive care. By and large, doctors perform the services they get paid for. Unfortunately, most holistic services are not covered by insurance at all.

Add in the extremely complex but very well paid insurance bureaucracies, an aging population, sedentary lifestyles, and a conventional food and beverage industry that continues to market cheap but disease-causing products, and you’ve got a recipe for a major health care disaster, which is exactly what is being seen in private practices.

Practicing medicine has become a struggle for many doctors, especially for those who want holistic/integrative practices. To make integrative medicine work, we need new business models that support the time-intensive, relationship-centered aspects of this approach. The re-emergence of fee-for-service models in which patients pay doctors directly, without the interference of third-party payers, and new developments like “concierge care” models in which patients pay yearly fees to be members of a physician’s prevention-oriented practice are steps in this direction, although the concierge approach has raised some ethical red flags in some medical circles.

There is also a resurgence of old-fashioned house-call medicine, along with new trends including corporate wellness programs, medical spas and wellness-oriented retirement homes, all of which provide new opportunities for holistically minded physicians.

Leading companies in the practitioner nutraceutical channel and the functional diagnostic testing field are responding to the needs for integrative care with comprehensive turn-key programs designed to make it easier for physicians to incorporate nutrition-based medicine into their practices.

All of these trends bode well for the future of integrative care, but we still have a long way to go. In the near term, primary care physicians need all the help they can get. It is clear from the growth of the natural products industry that consumers want and need holistic, integrative health care. The medical community is striving to meet those needs and to clear some of the political and economic roadblocks standing in the way.

Grace L. Keenan, M.D., received her medical degree from Memorial University School of Medicine, St. John’s, Newfoundland. She has been in private practice since 1988, founding Nova Medical Group. Dr. Keenan is a member of the American Professional Practice Association, Medical Society of Virginia, American College of Physicians, American Medical Association and MGMA. She is a clinical assistant professor at Georgetown University’s Department of Medicine and an affiliate faculty at George Mason University.

Dr. Keenan is chairing the inaugural conference, “Heal Thy Practice: Transforming Primary Care,” scheduled for Oct. 31 to Nov. 2 in Tucson, Ariz.; the conference will explore various business development and practice management strategies that support prevention-oriented integrative health care. More information is available online at HolisticPrimaryCare.net.