Summary: When it comes to motivation, money may be the queen among carrots and pain the king among sticks. Both financial gain and human pain may soon be promoting more rapid uptake of integrative medicine by mainstream organizations according to representatives from a major health system and the US military. The perspectives were shared during a forum entitled Integrative Medicine in Action sponsored by the Bravewell Collaborative of philanthropists in integrative medicine. If true, the long-standing struggle over misalignment of incentives between the health-oriented approach of integrative medicine and the disease-focus that spawned the $2.6 trillion medical industry may be finding a positive resolution. Obama's health reform and prescription pain-killers may be integrative medicine's best friends.
When it comes to motivation, money may be the queen among
carrots and pain the king among sticks.
Philanthropic group sponsored the event
Both are increasingly on the side of a more rapid uptake
of integrative medicine into mainstream delivery according to leaders of health
systems and military medicine. Representatives of each spoke on November 10,
2011 at "Integrative Medicine in Action," seminar sponsored by the
Bravewell Collaborative of philanthropists in integrative medicine that
preceded the Bravewell
Physician Leadership Award.
Moderator Jonathan LaPook, MD,
the CBS medical correspondent, set the tone at the educational session. He made
it clear that this year's program at the New
York Palace Hotel would not merely feature opinions on integrative medicine's purportedly
transformational philosophy, vision and mission. LaPook, who also moderated a
previous iteration of the biennial event, scanned the packed parlor room of
individuals who'd paid $250 a person to attend. He declared everyone present a
member of the choir. No more preaching, he said. This year the speakers would
deliver nuts-and-bolts on the state of integrating healing-oriented, whole
person, integrative care within large healthcare systems and into military
The field of integrative medicine has moved, as LaPook later put it, "from
generalities to the specifics" of implementation. He nodded toward a table
Lt. Colonel Windy
Hendrick sat. The F16 fighter pilot was to later present on the positive impact of her
integrative health coaching for returning veterans. LaPook joked that
if any speaker strayed into philosophizing, he'd pre-arranged with Hendrick to
have the back-slider strafed.
Jonathan LaPook, MD: CBS correspondent moderated
LaPook's jest on such a forceful motivational strategy touched the
day's pervasive theme. Do powerful incentives exist in the nation's $2.6-trillion payment and
delivery system to propel integrative medicine into a leading role in reform?
Close observers know that misaligned incentives are a badgering blues soundtrack
for integrative medicine's brief, 15-year history. The
field's health-oriented approach runs at counter-purpose to the disease-focus
that spawned the $2.6 trillion medical industry.
The challenge was captured recently Duke University Chancellor Emeritus
Ralph Snyderman, MD, a prior winner of
Bravewell's $100,000 prize. He wrote a column in
the Journal of the American Medical Association about an integrative
outpatient program at Duke University. The program saved $2200 per employee but
was killed by the system. Snyderman explained: "Ironically, because
reimbursement compensates in-hospital patient care at a higher level than
outpatient services, the health system realized a financial disadvantage, and
the program proved economically unsustainable."
Tracy Gaudet, MD: from IM to the the VA
In short, getting people healthy is not incentive enough.
Speaker Tracy Gaudet, MD, formerly a co-worker with Snyderman at the Duke's
integrative medicine program and currently the inaugural director of the Veteran's Health
Administration's Office of Patient-Centered Care and Cultural Transformation later put it this way: "The biggest mistake you can make
is to believe that everyone wants to make health better."
Notably, the rest of Duke's integrative medicine initiative has been sustained in
its first decade only through over $10-million of philanthropy from
John and Christy Mack,
the Bravewell evening's Diamond Benefactors and hosts.
A potential for financial alignment?
Ken Paulus says
this problematic financial climate for integrative medicine is about to be
turned on end. Paulus is president and CEO for Minnesota's dominant delivery
system, Allina Hospitals &
Clinics. He argued that the economic
obstacle to expansion of integrative medicine inside healthcare delivery will
change under the Affordable Care Act. Paulus recounted that Allina has "been in
this business of treating diseases for 100 years and we do it very well."
The system serves roughly a third of Minnesota's population. Then Paulus
referenced the soaring cost of care in the United States: "Being increasingly
broke completely changes the equation."
Paulus took a side-journey to underscore his point. He recounted a story he'd
heard that intrigued him about an ancient Chinese form of healthcare payment.
Barefoot doctors, he said, were only paid by communities if the people in their
charge were kept healthy. Fast forward to the new payment forms in Obama's
Accountable Care Organizations and Patient
Centered Medical Homes. "For the first time ever," said Paulus,
"the payment will change toward keeping people healthy." He repeated,
for emphasis: "For the first time in 100 years it will be our job at
Allina to keep the village healthy."
Ken Paulus, Allina CEO
This, Paulus concluded, is where Allina "is
headed." And this shift is "the point of inflection" for
"When I first heard of integrative medicine," he
told his audience," I saw you as an expense."
He credited philanthropic support via the Penny George Institute
for Health and Healing with keeping the integrative flame alive at Allina. "We've had benefactors for integrative
medicine. The George's [Family
Foundation] and the Ted and Roberta
Mann Foundation have bridged us to where we are going." But now Paulus
anticipates that when the Affordable Care Act's payment structure "kicks in that
supports keeping people healthy, you will be an asset. Integrative medicine
will be an asset."
Presenter Colonel Kevin Galloway turned attention to another well-known
motivator. Pain, he said, has brought the US military to adopt holistic and
integrative approaches. Galloway is chief of staff of the US Army's Pain
Management Task Force and action officer for the
Pain Management Campaign Plan. "In the past," shared Galloway,
"we used to say when you have more pain, give mor-phine."
Pain drives Army's interest in integrative medicine
This changed in a big way under the
and personal experience of Lt. General David Fridovich. Said Galloway: "He made
holistic okay. He redefined pain as a functional issue. He told the specialties
you need to stop fighting among the tribes and focus on what is the best
medicine." Galloway added: "We are rebuilding our system with a
multidisciplinary approach. We have acupuncturists and massage therapists
around our interventionists. We're forcing them to sit together."
Integrative medicine's emergence was captured in the
words, and presence, of Gaudet. The former Duke leader in integrative medicine now heads up the Veteran's Health
Administration's Office of Patient-Centered Care and Cultural Transformation. The
integrative medicine experience that informs Gaudet's work also includes an earlier
stint as director of the Arizona
Center for Integrative Medicine, founded by Andrew Weil, MD. Recalling that
pioneering work, Gaudet stated: "In 1996, we had to argue to just have a
conversation" about integrative medicine's potential value.
Colonel Kevin Galloway: Army initiative has team model
Gaudet took up LaPook's practical charge: "We need
to define what we mean by a transformed system. What is it that we want? We
need to define a personalized health plan. What is it?" She moved into the
nuts and bolts of the forms we use for gather patient outcomes related to pain. Gaudet suggested that a
pain scale in a health-oriented system would not merely reach from a 10 for intolerable pain to zero for pain free. She suggested that intolerable pain should be a -10 in a scale that stretches not merely to 0 but to a true positive of 10 for happiness. Her suggestion was evidence-based:
"We know that if patients have to fill in different boxes (in forms), behavior
changes." She added: "We have to hard-wire this change" toward a health-orientation.
To 1960s-era Baby Boomers who fostered the growth of the alternative, complementary and now
integrative medicine fields, the idea of military medicine leading the uptake
of soft-belly, integrative practices can seem oxymoronic. Similarly, conventional medical professionals don't much like thinking that in the US system, making money and
focusing on the health of our villages has too often proven an even more awkward fit.
To listen to the speakers brought together by the
Bravewell philanthropists, these cobbled motivators may yet launch integrative
medicine as the transformational agent the Bravewell's founders have advocated
for a decade.