CAM Treatments and Health Care Reform

In America’s complicated health insurance infrastructure, not everyone can receive private coverage. Some can’t afford it; others aren’t eligible for any one of a variety of reasons. But health care is a right and should be available to all citizens. Government programs are in place to cover many of those without access to private insurance, but as of now they don’t have the capacity to insure everyone who needs it.

In 2009, the Oregon Legislature created the Oregon Health Care Policy Board in order to create a comprehensive health reform plan for the state. The overarching goal for this plan is that by 2015 the large majority of Oregonians will have health care, whether through public or private insurance. The board outlined strategies that would move the state towards that goal, systematically implementing new policies and improving old ones.

The board determined three aims for the new health care system, as discussed in Oregon’s Action Plan for Health:

“Improve the lifelong health of all Oregonians; increase the quality, reliability and availability of care for all Oregonians; and lower or contain the cost of care so that is it affordable for everyone.”i

One of the questions these aims raise is whether insurance should cover all licensed health care practitioners – not just those in the tradition of Western medicine, but also those thought of as “alternative” options, such as chiropractic, acupuncture and massage. Research has demonstrated the effectiveness of many of these practices for a variety of medical needs. But with an already expanded population of insured individuals, would there be enough money to cover an expanded field of medicine? It turns out that Washington state already mandates such coverage for their private insurance providers. And a 2010 study showed that this addition of CAM (complementary and alternative medicine) to basic insurance plans can actually reduce costs in health care. Widening the scope of covered treatment while still controlling the cost of medical care is exactly the solution that Oregon needs.

Improving Lifelong Health
Beyond treating for acute issues, how can insurance coverage improve the health of its clients? This has a lot to do with shifting the focus of medical treatment from cures to prevention; stopping problems before they even become problems. A big goal for this approach – known as “holistic” medicine – is helping people adopt healthy lifestyles. For example, tobacco use, poor diet, and inactivity are three modifiable factors that are otherwise some of the biggest causes of health problems. Many medical practices have realized the benefits of holistic care, and so has the Oregon Action Plan: “The future: A holistic approach that focuses on the patient, not the symptoms, and emphasizes preventive care and healthy lifestyles.”ii

Quality, Reliability and Availability of Care
But no single doctor can wholly care for a client. The Oregon Action Plan wants to create “a community-based team of health care professionals, not just doctors, [who] will help keep people healthy and treat them when they are sick.”iii With different practitioners from a variety of backgrounds, medical teams will have a wider base of knowledge and be able to solve health problems more effectively.

And OHP is right to look beyond medical doctors to provide care. An April 12, 2010 article in the Wall Street Journal states, “Experts warn there won’t be enough doctors to treat the millions of people newly insured under the law. At current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges.”iv Utilizing a wide range of health care providers isn’t just a good idea; it’s a necessary one.

But how can a team of medical professionals really be effective if they aren’t all covered by insurance? CAM treatments, such as acupuncture and massage, are still considered a privilege, a fancy addition for expensive insurance plans. But proper treatment shouldn’t just be available for those who can afford it. If the future of medicine is to work in teams, with each practitioner able to contribute his or her expertise towards a patient’s better health, every practitioner should be covered equally by insurance. If a patient’s doctor refers her for massage, why should she have to pay out of pocket for this treatment? Without comprehensive coverage, she’ll be less likely to get the medical care that she needs.

As mentioned in the Action Plan, an estimated 30% of care is either not necessary or ineffectivev. People are spending money on treatments that aren’t actually solving any problems. But research exists that supports the effectiveness of many CAM treatments for a variety of conditions. Massage therapy, for example, is good for muscle painvi, depressionvii, stressviii, anxiety from drug withdrawalix, pain and anxiety from cancer treatmentx, hormone imbalancexi, and immune functionxii xiii, among many other physical and emotional issues. From this wide range of research, it’s easy to see that massage has benefits both for acute problems and preventative care, making it a natural addition to any health care team.

Containing Costs
Holistic care is a great idea for many reasons – stopping problems before they become problems, encouraging healthy lifestyles, and even saving money: “Focusing on prevention will yield significant returns on investments by improving health.”xiv Preventing disease and staying healthy cost less than treating or managing problems once they arise.

Unfortunately though, there are plenty of people with severe problems already, and despite best efforts there will be more. Chronic pain, for example, is a condition that affects “more than 75 million Americans…over 50 million of these individuals are partially or totally disabled from pain.”xv Not only is this widespread, but it seriously impacts productivity: Chronic pain costs more than 50 million lost workdays at a cost of more than $3 billion in lost wages and more than $100 billion in lost productivityxvi. How can we get a handle on this disease?

While painkillers and other drugs are the most common solution for chronic pain, the most effective treatment is a holistic onexvii. Through things such as psychotherapy, nutritional evaluations, and relaxation massages, treating the patient for all symptoms – mental and emotional, not just physical – is the best solution. By focusing on the bigger picture when it comes to chronic conditions, and working not just to minimize symptoms but also to make lives better, medical costs can be cut and productivity can increase.

CAM and Cost Savings
As outlined above, improving health through holistic care is cost effective. And a huge part of this type of care is CAM treatments – naturopathic and chiropractic medicine, acupuncture and massage. Because these therapies don’t depend on expensive technologies or pharmaceuticals, and instead “harness the power of vis medicatrix naturae (the body’s natural ability to heal itself)”xviii, could CAM treatments alone save money? Recent research suggests that they doxix.

Beginning in 1996, the state of Washington mandated that private insurance companies must cover every category of health care provider given that the provider is providing treatment for a basic service that he or she is licensed for. In short, that means CAM providers in the state of Washington are covered under private insurance policies in the same way that conventional providers are covered. A visit to an acupuncturist, for example, would be available for the same copay as a visit to a medical doctor.

From the mandate:

“(1) Every health plan delivered, issued for delivery, or renewed by a health carrier on and after January 1, 1996, shall:
(a) Permit every category of health care provider to provide health services or care for conditions included in the basic health plan services to the extent that:
(i) The provision of such health services or care is within the health care providers’ permitted scope of practice; and
(ii) The providers agree to abide by standards related to:
(A) Provision, utilization review, and cost containment of health services;
(B) Management and administrative procedures; and
(C) Provision of cost-effective and clinically efficacious health services.” xx

This wouldn’t mean that everyone in Washington would start getting CAM treatments, but it would mean that those who did utilize CAM weren’t just those who could afford to pay out-of-pocket. Recently, researchers took a look at two years worth of claims to see if patients who did and did not use CAM treatments differed in total medical expenses.

Because most CAM research relies on self-reported data (ie, whether the patient feels better after a treatment), these studies often have an inherent bias. Whether or not CAM treatments provide tangible evidence of being effective, they often lead to a general sense of well-being. While the interaction between mental and physical health cannot be denied, this was not what researchers wanted to study. Rather, this study took a “cost-minimization approach” in order to find out whether CAM users differed from nonusers in their medical costs.

In an analysis of insurance expenditures for matched groups of CAM users and CAM nonusers, it was found that CAM users had significantly lower overall expenditures. Specifically, while they did have a slightly higher expenditure for outpatient visits (including massage appointments, chiropractic adjustments, etc, which the other group – by definition – did not utilize), inpatient expenditures and other expenditures (imaging, lab work, etc) were significantly lower. It was found that CAM users were less likely to be hospitalized, less likely to get a hysterectomy within one year of diagnosis, and more likely to have some type of imaging done and done early. Although having more imaging done should seemingly be more expensive, the imaging was typically of a less expensive variety. And because the imaging was done early, it had the benefit of being a preventative measure.

Researchers predicted that, given the findings, CAM users would save an enormous amount of money:

“Given the expected $356 lower expenditures for each CAM user, we would expect an overall $9.4 million lower expenditure in a group of 26,466 CAM patients with these medical conditions compared to a similar group of CAM nonusers of equal size.” (pg 415-416)

For some analyses, subjects were divided into three levels of “disease burden”, which created groups based on their expected resource use. The low disease burden group were generally healthy individuals, high disease burden group were generally unhealthy individuals, and the medium disease burden group was in between these two. When divided in this way, CAM users in the low and medium groups had higher overall expenditures than CAM nonusers – they had more outpatient visits to CAM providers, and neither group had many inpatient visits or labs. But in the high disease burden group, CAM users had significantly lower expenditures than nonusers, which more than made up for the higher expenses of the healthier groups. CAM was used for preventative care by the high risk group, just like in the other groups, but it was also the less expensive way to treat acute problems.

OHP
OHP (Oregon Health Plan) is Oregon’s Medicaid program for low-income adults. While it insures many, space is limited and it had been closed to new enrollment for years. In 2008, Oregon increased the number of spots available for the program. Because it couldn’t accept everyone on the waiting list of 90,000 people, it utilized a lottery system for a randomized and fair selection.

A paper was released in July 2011xxi that discussed the effects of the expanded OHP coverage after the first year. Were people actually taking advantage of their new health care coverage? This paper affirmed that the intension of the Medicaid expansion – that people who needed coverage were using it – was the reality. OHP patients had significantly higher health care utilization, less out of pocket expenses, and better reported physical and mental health than those who had not been chosen to receive OHP.

The paper also notes that those with OHP coverage are generally in poor health, with high rates of depression, asthma, diabetes and high blood pressure. Were they to have been in the Washington study, they probably would have been placed in the high disease burden category. There’s no reason to expect, then, that the medical savings found in the Washington study would be any different than if OHP covered CAM treatments. After all, the strongest finding in the study came from this group – mean expenses for CAM users were predicted to be $1,421 lower than nonusers. The message is clear: Making CAM treatments available through insurance, especially insurance like OHP, will save money.

The Oregon Action Plan for Health said it best when it talked about the need for a holistic approach to health. The world is moving towards using teams of health care professionals, not just doctors, in order for patients to get the most benefit. But for this to happen most effectively, insurance would need to cover all health care providers. By covering CAM therapies, OHP would be satisfying each part of its Triple Aim. Improving lifelong health: Along with acute care, CAM providers focus on holistic and preventative treatments. Increasing quality, reliability, and availability of care: Including CAM practitioners in insurance coverage will widen the scope and availability of treatment. Covering costs: It’s impossible to ignore the evidence found in the Washington CAM paper – overall, CAM users cost significantly less than their counterparts. The addition of CAM therapies to even the most basic health plans will result in medical care that is effective, affordable, and available to all.

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i Oregon Health Authority. December 2010. Oregon’s Action Plan for Health, pp 5.
ii Oregon’s Action Plan for Health, pp 22.
iii Oregon’s Action Plan for Health, pp 22.
iv Sataline, S., Wang, S. U.S. Faces Shortage of Doctors: Medical Schools Can’t Keep Up. The Wall Street Journal, April 12, 2010.
v Kimbuende, E., Ranji, U., Lundy, J., Salganicoff, A.U.S. Health Care Costs. KaiserEDU.org. Retried August 8, 2011, from http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx.
vi Preyde, M. (2000). Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. CMAJ, 162, 1815-1820.
vii Field, T., Grizzle, N., Scafidi, F., & Schanberg, S. (1996). Massage and relaxation therapies’ effects on depressed adolescent mothers. Adolescence, 31, 903-911.
viii Hayes, J., Cox, C. (1999). Immediate effects of a five-minute foot massage on patients in critical care. Intensive and Critical Care Nursing, 15, 77-82.
ix Black, S., Jacques, K., Webber, A., Spurr, K., Carey, E., Hebb, A. & Gilbert, R. (2010). Chair massage for treating anxiety in patients withdrawing from psychoactive drugs. Journal of Alternative Complementary Medicine, 126, 979-987.
x Smith, M.C., Kemp, J., Hemphill, L., & Vojir, C.P. (2002). Outcomes of therapeutic massage for hospitalized cancer patients. Journal of Nursing Scholarship, 34, 257-262.
xi Field T, Hernandez-Reif M, Diego M, Schanberg S, Kuhn C. (2005). Cortisol Decreases and Serotonin and Dopamine Increase Following Massage Therapy. International Journal of Neuroscience, 115(10), 1397-1413.
xii Ironson, G., Field, T., Scafidi, F., Hashimoto, M., Kumar, M., Kumar, A., Price, A., Goncalves, A., 2, Burman, I., Tetenman, C., Patarca, R., Fletcher, M. (1996). Massage Therapy is Associated with Enhancement of the Immune System’s Cytotoxic Capacity. International Journal of Neuroscience, 84(1), 205-217.
xiii Billhulta, A., Lindholm, C., Gunnarsson, R., Stener-Victorina, E. (2009). The effect of massage on immune function and stress in women with breast cancer — A randomized controlled trial. Autonomic Neuroscience, 150(1), 111-115.
xiv Oregon’s Action Plan for Health, pp 30.
xv Joint Commission on the Accreditation of Healthcare Organizations. Pain: Current Understanding of Assessment, Management, and Treatments. Oakbrook Terrace, IL: Joint Commission on the Accreditation of Healthcare Organizations; 2001.
xvi Fox CD, Berger D, Fine PG et al. Pain assessment and treatment in the managed care environment. A position statement from the American Pain Society. Glenview, IL American Pain Society; 2000.
xvii Grumbach, K., (2003). Chronic Illness, Comorbidities, and the Need for Medical Generalism. Annals of Family Medicine, 1, 4-7.
xviii Herman, P., Craig B., Caspi O. (2005). Is Complementary and Alternative Medicine (CAM) Cost-effective? A Systematic Review. BMC Complementary and Alternative Medicine, 2, 5-11.
xix Lind, B., Lafferty, W., Tyree, P., Diehr, P. (2010). Comparison of Health Care Expenditures Among Insured Users and Nonusers of Complementary and Alternative Medicine in Washington State: A Cost Minimization Analysis. The Journal of Alternative and Complementary Medicine, 16, 411-417.
xx Partial text of RCW 48.43.045 from Washington State Legislature.
xxi Finkelstein, A., Taubman, S., Wright, B., Bernstein, M., Gruber, J., Allen, H., Baicker, K., The Oregon Health Study Group. The Oregon Health Insurance Experiment: Evidence From The First Year. NBER Working Paper No. 17190, July 2011.

 

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