| ||Invited Commentary on the NCCAM Survey: Stephen Bolles, DC asks if the CAM Industry is Mature, Immature or Simply Misunderstood||
Summary: "I'm beginning to wonder if some new model of looking at the CAM/integrative health care markets may be required." So writes Stephen Bolles, DC, in this thoughtful reflection on the controversial NCCAM survey which concluded that the visits to CAM practitioners may have dropped 50% between 1997 and 2007. Bolles, who spent many years looking at the consumer and CAM from inside the leadership of a consumer division of United Health Group, writes: "To me (the NCCAM report) is kind of like an eloquent and detailed answer to a problem that hasn't been defined." This invited column touches on the "seduction" of the dollars projected in the first Eisenberg study then presents ideas about how to think about the CAM consumer, the CAM industry, and how to create a successful business with the CAM-using clientele.
Shortly after publishing the Integrator Special Report, I received a brief response from Stephen Bolles, DC, which I included among 9 responses here. Basically, he thanked me for the work. I immediately wrote back to Bolles, telling him that I bet he had more to say than that, given the importance of data on CAM use to business planning.
Stephen Bolles, DC
I pushed Bolles because he had spent a half-decade thinking about the consumer's relationship to complementary and alternative medicine as a leader of a team with a United Health Group affiliate. And this was after service as an executive at the multidisciplinary Northwestern Health Sciences University where he played key roles in helping fashion an early integrative clinic in a health system in the Twin Cities of Minnesota, his base. He has plenty of useful perspective.
Bolles responded with this insightful reflection, which should prove interesting to anyone who ever wondered about how big consumer use and interest really is, or who has tried to build a business in this arena.
Questions that the NCCAM Data Raise:
Is the CAM Industry Mature, Immature or Simply Misunderstood?
Stephen Bolles, DC
The thing that stood out to me initially, as to everyone, were the
bold numbers (in NCCAM's findings). Hard on the heels of that came the head-scratcher of the
familiar issue: How many people in how many ways have tried to capitalize on
these numbers in various types of service businesses?
The products businesses
do well with good products and good business planning, but the service side of
things seems off somehow. I've wondered if the CAM service segment of health
care is either a) mature, and this is (or was) as good as it's going to get; b)
mature, fragmented but possessed of a reservoir or latent energy that hasn't
been effectively tapped or focused; c) immature, missing some type of focusing
or developmental dynamic required to guide or direct it; or d) simply
misunderstood in the terms we are using.
I'm beginning to wonder
if some new model of looking
care markets may be required.
Much as there's talk about new paradigms in viewing health and
disease, I'm beginning to wonder if some new model of looking at the
CAM/integrative health care markets may be required. I am wondering if it ends
up being helpful to develop a model that layers types of markets on each
other--separated by some distinction in the consumption dynamics.
I am not sure yet
what the categories might be based on, but one initial thought might be to base
them on identifying the beneficiary of the transaction. Or whether the
consumption was based on controlling disease/fixing problems vs.
promoting/assuring wellness or avoiding malaise. Or whether consumption
decisions are based on a relationship with someone or not.
You know how many
have been seduced by the dollar
numbers that have been available,
form or another, since
Eisenberg's initial study.
I am not sure, but it
seems to me that without some new model the NCCAM data as interpreted really
don't tell us much that's useful. To me it's kind of like an eloquent and detailed
answer to a problem that hasn't been defined. The market segments are clearly
related and interconnected, but I am wondering if the NCCAM results are
confusing in part because of the lack of this distinction.
I share, I think, your suspicion of the numbers, and not just
because CAM use appears flat or contracting. You know better than most how many
people have been seduced by the dollar numbers that have been available, in one
form or another, since Eisenberg's initial study. I wouldn't even venture to
guess how many business plans have been written where those numbers stand as
testament to the richness of the opportunity; just reviewed another one this
week that could have been written twenty years ago--and probably was. But as we
observers and pained members of the Fraternity of The Failed can attest,
actually getting at that revenue flow is harder than it looks. It has
challenged me to think of how one might be able to predictably, effectively and
reproducibly carve off a chunk of those dollars. They're clearly flowing out
there, somewhere. But I don't know if anyone's found the secret sauce yet.
Perhaps that is because we've failed to appreciate the right
marketplace segmentation model. From where I sit, I think there is a persistent
misunderstanding of what may be the basis for a consumption decision--the
calculus of value that goes into someone buying something from someone (more
than once, which I think you astutely identify as an important metric in
returning or sustained CAM treatment). I think that without that understanding,
its easy to come up with research answers that don't explain anything.
observers and pained
members of the Fraternity of
The Failed can attest,
getting at that revenue flow
is harder than it looks.
this misunderstanding is evident in mainstream CAM provider business practices.
It looks to me like they seem to be on a collision course with a dire and
painful marketplace shakeout and financial reckoning. One of my soapbox
statements is that chiropractic, after 114 years of existence, has been at a
flat market penetration rate of 7-10% for decades--but churning out graduates
at a rate higher than population growth can absorb and keep practices flat or
growing. That's not a recipe for success.
I don't think people don't use CAM carelessly. They may use it without guidance; they may
use it experimentally, but because it costs real money for just about everyone,
it's not possible for many people to use it without concern. As I look around
the professions I know, it strikes me that most of what I see are strategies of
systemic engagement. As important as those are, I worry that as hard as we
continue to work to become embedded in the delivery system, the health care
transaction system has been moving to put consumers in a position where the
delivery system matters less and less. If health care consumption decisions are
coming to be based more and more on retail decision dynamics, I fear for our
future, because I don't see many visible conversations about how to focus on
the issue of value as a way of promoting consumer adoption. We providers tend
to see our services in terms of solutions to problems people come in the door
with, but many consumers, I believe, are coming to think in very different terms--because
they employ a calculus of (often very personal) components of value. Clinical
and functional outcomes certainly matter. But price, access, amenities, bundled
providers, peer network support, are also factors I don't hear us talking about
very much. They are marketing adjuncts to some, but not adoption strategies for
As hard as CAM professions are
working to become embedded in
the delivery system, the healthcare
transaction system has been moving
to put consumers in a position where
delivery system matters
less and less.
I think this matters at all because of how we CAM providers have
most frequently tried to position ourselves in our own marketplace. The terms I
hear and have tracked over time now, I fear, have become not irrelevant but
incomplete. I fear that our strategic position has kind of ossified, and I'm
not sure we understand what's going to be required of us in the coming
iterations of health care delivery and transaction financing (regardless of
health care reform). I badly want to be proven wrong on this.
I fear for our
I don't see many visible
conversations about how to
the issue of value
as a way of promoting
For instance, it seems that CAM providers should be loved by insurance plans, but insurers
don't care if we save them money. Chiropractic has unsuccessfully argued this
for years, with very few takers. Insurers only ended up caring whether they
could successfully control our costs. Short of sheer lobbying force, coverage
for other providers' services has only come (I would submit) from insurers'
ability to sell coverage products to someone. That's why, in my view, we've
ended up with discount affinity products dominating the marketplace. We have
not succeeded in describing our value in terms that matter to the industry, and
the terms of value that insurers' customers can articulate have found the
appropriate match: discount affinity products.
So back to NCCAM. Outside of the important statistical
characteristics you identify, I think that one of the problems in understanding
the data in comparison to prior studies goes to the difference in markets. The
health care marketplace in the early 1980s [when the CAM movement began gaining momentum] is quite different than today. The
expansion and contraction of insurance coverage for CAM notwithstanding, the
generational shifts, profound changes in transaction tools and dynamics, the worsening
of the national chronic disease emergency that have taken place in the last 30
years all say to me that if we're asking the same questions we were back then,
we are probably not asking the right questions now.
If we're asking the same questions
we were 30 years ago,
we are probably
not asking the right questions now.
But at least we're asking them, and challenging what we think we
know can only improve our understanding.
Peace and health,
Comment: I find a good deal of this challenging, as it is stimulating.
We have basked too much in a sense
of manifest destiny, in the idea that
the consumer wants us.
The destiny suggested by the NCCAM
study is contraction.
Where I land with two feet is with Bolles' "fear for our
future" because he doesn't "see many visible conversations about how to focus on
the issue of value ..."
Bolles focuses, still, on "consumer adoption." I think the issue is paying enough attention to value in creating adoption of all sorts, by all stakeholder purchasers - employer, government as well as the consumer. We have not, for instance, created and promoted
our own strategies for showing cost value. We have neither developed
the internal competencies to focus on measuring practical values nor
engaged the campaigns with NCCAM or the Federal Coordinating Council
for Comparative Effectiveness Research, about which Calabrese writes here.
Instead, we have basked too much in a sense of manifest destiny, in the idea that the consumer wants us. This NCCAM study projects, correctly or incorrectly, that the only destiny that is presently manifest is one of contraction.
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