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Integrative Medicine and Public Policy 

Integrative Medicine and Public Policy
Chapter:
Integrative Medicine and Public Policy
Author(s):

Josephine P. Briggs

DOI:
10.1093/med/9780190241254.003.0022
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date: 23 September 2020

Introduction

Integrative medicine represents both a challenge to conventional medical care and an opportunity for change. The challenge arises from the familiar concerns about shortcomings in our conventional ways of caring for patients. The last few decades have seen enormous strides in our ability to change the course of many chronic diseases. Cardiovascular disease, kidney disease, many cancers—the care we can offer today for many of these conditions is measurably and often dramatically better than it was 20 or 30 years ago. But the demands and pace of modern medicine are omnipresent, and the subjective experience of patients is not improving. The criticisms of conventional care are familiar: Care is disease-centric rather than patient-centric; poor coordination results in costly redundancies like duplicate tests; and our conventional methods of care fail to effectively engage patients in more effective self-care. It is clear there will be no simple answers to these challenges. Integrative medicine offers a philosophy of care that is patient-centric, and a strategy to address some of these widely acknowledged shortcomings of the standard modes for delivery of care. The centerpiece of integrative medicine is a strategy to more effectively engage patients in their own care.

Other chapters in this book discuss the specific modalities that are being integrated into care by integrative medicine providers, as well as the integrative medicine approach to prevention and treatment of specific diseases and symptoms. In this chapter we summarize the public resources supporting the development of integrative medicine and some of the policy and regulatory implications of the model of integrative care that starts with the personal perspective of the patient.

Encouraging Patient Self-Education

A major change in healthcare delivery is the changing dialogue between the patient and healthcare providers. The practice of integrative medicine incorporates an acknowledgment that an important starting point for all discussion is the identification of the elements of health most important to the patient.

Patient self-education is playing an increasing role in the dialogue with healthcare providers. The availability of extensive Internet resources providing information about health and disease—both reliable and unreliable—has had dramatic impact on the conversations between doctors and patients. The impact of these sources of information is felt in almost all patient encounters. Physicians often feel concerned about these resources and stretched to provide reliable information in the time constraints of short clinical visits. Patients need information about what resources to trust and guidance in distinguishing reliable information from marketing. Listed in Table 22.1 are the major federal public health websites that provide general information about health and disease. Table 22.2 provides a list of websites from both the private and public sectors that focus on complementary health practices. Healthcare providers need to be able to provide guidance to the availability of helpful resources and help patients distinguish reliable Web information from questionable sources.

Table 22.1 Federal Public Health Resources for General Information About Health and Disease

Centers for Disease Control and Prevention (CDC)

National Institutes of Health (NIH)

National Library of Medicine, MedlinePlus

US Department of Agriculture (USDA)

Substance Abuse and Mental Health Services Administration (SAMHSA)

Table 22.2 Private and Public Sector Resources on Complementary Health Approaches

Cochrane Collaboration Complementary Medicine Reviews

  • This website offers rigorous systematic reviews of mainstream and complementary health interventions using standardized methods. It includes more than 300 reviews of complementary health approaches. Complete reviews require institutional or individual subscription, but summaries are available to the public.

  • http://www.cochrane.org

Mayo Clinic

  • National Library of Medicine, MedlinePlus

  • MedlinePlus All Herbs and Supplements MedlinePlus Complementary and Integrative Medicine

NIH National Center for Complementary and Integrative Health (NCCIH)

  • The National Institutes of Health NCCIH website contains consumer information on many aspects of complementary and integrative health approaches. Downloadable information sheets include brief summaries of complementary approaches and uses and risks of herbal and dietary supplements.

  • http://www.nccih.nih.gov

NIH Office of Dietary Supplements (ODS)

  • The National Institutes of Health ODS website offers resources to strengthen the public’s knowledge of dietary supplements. Its resources include publications on specific supplements, consumer safety, and decision-making.

  • https://ods.od.nih.gov/

US Food and Drug Administration (FDA) Consumer Information on Dietary Supplements

An interest in complementary health practices is often recognized by integrative medicine providers as a useful step in self-care, not a barrier to good care. It has been well documented that patients do not consistently inform physicians about an interest in complementary health practices or in the use of dietary supplements.1,2 Failure to open this conversation creates a barrier to identification of possible adverse effects of combining some dietary supplements, particularly herbal agents, with certain conventional pharmaceutical agents. Drug-drug interactions are probably an even greater concern, since Americans, particularly older Americans, take many pharmaceutical agents concomitantly, including conventional drugs, over-the-counter medicines, and dietary supplements.

Research on Complementary Practices and the Development of an Evidence-Base for the Practice of Integrative Medicine

As discussed in earlier chapters in this textbook, most integrative practitioners incorporate a variety of complementary approaches into the care they offer patients. The evidence for the effectiveness of these interventions is incomplete but is expanding rapidly. Excellent resources to assess the state of the current evidence are the systematic reviews performed by the Cochrane Collaboration, which includes reviews on approximately 300 complementary and integrative medicine topics (http://www.cochrane.org). While these resources are valuable, the methods place heavy reliance on randomized trials, which generally compare two similar modalities, or the intervention with a control. With rare exceptions the available evidence often does not provide answers to the practical questions faced by clinicians, such as comparisons between the risks and benefits of conventional pharmaceuticals and integrative approaches. This shortcoming in the evidence base is not confined to complementary health approaches or integrative medicine. Recent reviewers have commented that many of the practices used in conventional care, perhaps as many as half, also lack a solid evidence base.3,4 Similarly, there is a shortage of trials that compare exercise with drugs.5

Nonetheless, the evidence base is growing. Pain management provides an informative example of the way complementary approaches are becoming part of an evidence-based integrative approach to care. Evidence-based algorithms for care of patients with chronic pain increasingly acknowledge and incorporate nonpharmacologic practices that until recently have not been part of standard conventional care.6 A useful example is the management of back pain, as shown in Figure 22.1. In addition, several guidelines that may be useful in the diagnosis and management of pain are listed in Box 22.1.

Figure 22.1 Management of Nonspecific Chronic Low-Back Pain

Figure 22.1 Management of Nonspecific Chronic Low-Back Pain

Source: Adapted from reference 6.

Ultimately, making the best choices about policies for healthcare requires access to high-quality evidence to guide those choices. Health policy makers increasingly acknowledge the need for standardized and critical analysis of the level of evidence to guide the development of policy and inform personal choices. The assessment of evidence for guidelines on clinical treatments will almost certainly continue to rely heavily on randomized clinical trials. Prevention poses different challenges, however. The approach to the development of standards for preventive modalities is largely led by the US Prevention Task Force (USPTF), and under the Affordable Care Act, their guidelines influence reimbursement decisions. With rare exceptions, approaches to prevention, such as screening tests, have not been tested by large randomized trials, in large part because the sample size requirements make such trials overly expensive and impractical. The USPTF relies on the development of a chain of evidence, relying on a mix of data from randomized trials and observational data to establish quantitative estimates of risks and benefits. This approach is potentially applicable to the systematic study of prevention approaches in integrative medicine. Methods to study complex interventions while retaining the rigor created by randomization include cluster-randomized trials or trials that incorporate a randomized approach to staged implementation.7 The NIH Health Care Systems Research Collaboratory (http://www.nihcollaboratory.org) is pioneering the development of these approaches.

Professional Standards for Integrative Medicine and for Complementary Healthcare Providers

A patchwork of regulations and standards governs the practice of integrative medicine and care provided by associated healthcare providers. In the United States, medical licensure is the responsibility of state government. The development of standards for medical subspecialties is the responsibility of professional accrediting organizations or commissions recognized by the US Department of Education (ED).8 Standards for professional education and curriculum standards are largely established by commissions also overseen by the ED.

Integrative medicine is a subspecialty in transition. Some practitioners have viewed the goal of integrative medicine as a change in the process of care applicable to all specialties, and have argued that subspecialization would not serve the broader goals of promotion of change across all medical practices. However, in the last 3 to 5 years, some leaders in integrative medicine have concluded that a formal subspecialty designation is desirable and have established the American Board of Integrative Medicine (ABOIM) under the aegis to the American Board of Physician Specialties. They have established the following definition:9

The ABOIM defines integrative medicine as 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, healthcare professionals and disciplines to achieve optimal health and healing.

The ABOIM has established criteria for accreditation of fellowship programs and credentialing integrative physician providers including specification of the training requirements and development of examinations. Currently, 23 fellowship programs are accredited in the United States.9

Not surprisingly, there is even greater state-to-state variation in the approaches to licensure of complementary practitioners. Furthermore, healthcare providers vary in how they approach the credentialing of practitioners of complementary modalities. The complexities and uncertainties around credentialing complementary practices remain a barrier to their effective integration with conventional medicine.

At present five forms of complementary practice—chiropractic, therapeutic massage, naturopathy, homeopathy, and acupuncture and traditional Chinese medicine—are subject to some form of licensure requirements or educational requirements. Mind and body practices including meditation, biofeedback, and other relaxation techniques and meditative exercise forms such as yoga, tai chi, or qi gong are not subject to licensure requirements in any state. Practitioners of integrative health generally place emphasis on a team-based model of care, integrating a variety of clinical disciplines, including nutritionists, exercise therapists, and behavioral coaches and psychologists. Many nurses and physical therapists integrate these complementary approaches in their practices, either by obtaining expertise themselves or by referral. Nurses, in particular, have been early proponents of integrative medicine policy. For example, the Gillette Nursing Summit in 2002 was convened to “identify common concerns and a set of core recommendations that would enable nurses to provide leadership in this emerging field” of integrative health. Recommendations on integrative medicine that stemmed from this meeting covered areas of research, education, clinical care, and policy.10

Chiropractic

Chiropractic care is currently licensed in all 50 states and the District of Columbia and is reimbursed by Medicare.11,12 Licensure standards are largely determined by the main chiropractic professional organizations: the American Chiropractic Association, the Federation of Chiropractic Licensing Boards, and the Council on Chiropractic Education.11 Two years of undergraduate training and 4 years of professional training at an accredited institution are required for licensure, and most states require the successful completion of the standardized board examination; the discipline does not have a postgraduate training requirement. Many states require chiropractors to earn annual continuing education credits to maintain their licenses. There is some state-to-state variability in scope of practice; chiropractors are, in general, not authorized to prescribe drugs or perform surgery, but in most states, they may dispense or sell dietary supplements.11,13,14

Therapeutic Massage

Massage therapists are the most numerous of the regulated complementary health practitioner groups and the most rapidly growing.15 Insurance coverage of massage therapy has been mandated in the state of Washington since 1995,16 and massage therapists are increasingly incorporated into conventional health practices.17 Forty-two states impose some regulation of massage therapy, and although there is no consistency, typical requirements include 500 hours of training in an accredited postsecondary institution.15 The American Massage Therapy Association is generally recognized as the leading professional organization; it established an ED-recognized Commission on Massage Therapy Accreditation (COMTA), which has accredited approximately 100 schools.18 Most massage schools are not accredited, however, and many states have no licensure requirements.11

Naturopathy

Naturopathy or naturopathic medicine is currently licensed in 15 states and the District of Columbia, although the profession is actively seeking licensure in a number of other states.19 There are five accredited educational institutions in the United States. Licensure requires completion of a 4-year postbaccalaureate program with a curriculum that includes medical science and traditional naturopathic training. Although not required, many graduates complete a year or more of postgraduate training.16 All states that license naturopaths consider them to be doctors or physicians with the title of doctor of naturopathic medicine (ND) or naturopathic physician (NP).20

Homeopathy

Homeopathy has been practiced in the United States since the 19th century, but licensure as a homeopathic practitioner is available only in three states (Arizona, Connecticut, and Nevada) and then only to licensed physicians.11 Some states include homeopathy within the scope of practice of other fields, including chiropractic, naturopathy, and physical therapy,11 and some lay and professional providers self-identify as homeopathic practitioners,12 making estimates of the number of practitioners uncertain.

Acupuncture and Traditional Chinese Medicine

Acupuncture was first licensed in Nevada, Oregon, and Maryland in 1973, and it is currently licensed in 42 states and the District of Columbia, with licensure standards varying widely but generally including 3 years of accredited training and successful completion of a standardized examination.11 The ED-recognized Accreditation Commission for Acupuncture and Oriental Medicine is the main accreditation body.21 In 31 states, acupuncture is expressly included in MD and DO licensure; 11 states require additional training for physicians performing acupuncture.11

Costs of Complementary and Alternative Medical Care and Reimbursement Practices

The most recent data suggest that most complementary health practices are paid for out of pocket.22 (See Figure 22.2.) Total out-of-pocket spending for complementary approaches in 2012 was $30.2 billion—$28.3 billion for adults and $1.9 billion for children—representing 9.2% of all out-of-pocket spending by Americans on healthcare and 1.1% of total healthcare spending.22

Figure 22.2 Out-of-Pocket Spending, 2012

Figure 22.2 Out-of-Pocket Spending, 2012

*National Health Expenditure Data for 2012. US Department of Health and Human Services, Centers for Medicare and Medicaid Services Website. https://www.cms.gov/Research-Statistics-Data-and-systems/Statistics-Trends-and-reports/NationalHealthExpendData/index.html. Accessed March 31, 2016.

†Self-Care Purchases includes, for example, homeopathic medicines and self-help materials, such as books or CDs related to complementary health topics.

‡Other conventional care includes dental care, nursing homes, home healthcare, nondrug medical products, hospital care, and other professional services.

Source: Nahin RL, Barnes PM, Stussman BJ. Expenditures on Complementary Health Approaches: United States, 2012. National Health Statistics Reports. Hyattsville, MD: National Center for Health Statistics. 2016.

There is wide variation between insurance plans in the coverage of complementary interventions. Section 2706 of the Affordable Care Act contains the following provision: “A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license of certification under the applicable State law.”23

This provision for coverage of care is limited to licensed providers and does not impact on payment for interventions such as yoga classes or training in meditation that are not provided by licensed providers.

Several studies have brought the methods of cost-effective analysis to study the impact of complementary and integrative medicine on overall healthcare costs.24 By and large, these analyses suggest that coverage of complementary and integrative health, when available, is not necessarily associated with an increase in health costs.25

Conclusion

Integrative medicine offers opportunities to more effectively engage patients in their own healthcare by encouraging self-education and guiding patients to credible sources of information. In addition to patients, healthcare providers and health policy makers require access to rigorous evidence and a critical analysis of evidence to make the best decisions—those that will impact patients and policy. The regulations and standards that govern the practice of integrative medicine vary widely, as do the licensing and credentialing of complementary health practitioners—a barrier to their effective integration with conventional medicine. Another barrier that impacts full integration is the variation in insurance coverage of specific complementary approaches, and as a consequence, patients must pay for most complementary health interventions out-of-pocket.

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