J Manipulative Physiol Ther 2007 (May); 30 (4): 263–269
Richard L. Sarnat, MD, James Winterstein, DC, Jerrilyn A. Cambron, DC, PhD
Alternative Medicine Integration Group, LP,
Highland Park, Ill 60035, USA.
The initial report (JMPT 2004 (Jun) ; 27 (5): 336–347) analyzed clinical and cost utilization data from the years 1999 to 2002 for an integrative medicine independent physician association (IPA) whose primary care physicians (PCPs) were exclusively doctors of chiropractic.
This report updates the subsequent utilization data from the IPA for the years 2003 to 2005 and includes first-time comparisons in data points among PCPs of different licensures who were oriented toward complementary and alternative medicine (CAM). The authors found that: “During the past 7 years, and with a larger population than originally reported, the CAM-oriented PCPs using a nonsurgical/nonpharmaceutical approach demonstrated reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone.”
The savings? Clinical and cost utilization based on 70,274 member-months over a 7-year period demonstrated decreases of 60.2% in-hospital admissions, 59.0% less hospital days, 62.0% less outpatient surgeries and procedures, and 85% less pharmaceutical costs when compared with conventional medicine IPA performance for the same health maintenance organization product in the same geography and time frame.
OBJECTIVE: Our initial report analyzed clinical and cost utilization data from the years 1999 to 2002 for an integrative medicine independent physician association (IPA) whose primary care physicians (PCPs) were exclusively doctors of chiropractic. This report updates the subsequent utilization data from the IPA for the years 2003 to 2005 and includes first-time comparisons in data points among PCPs of different licensures who were oriented toward complementary and alternative medicine (CAM).
METHODS: Independent physician association-incurred claims and stratified random patient surveys were descriptively analyzed for clinical utilization, cost offsets, and member satisfaction compared with conventional medical IPA normative values. Comparisons to our original publication's comparative blinded data, using nonrandom matched comparison groups, were descriptively analyzed for differences in age/sex demographics and disease profiles to examine sample bias.
RESULTS: Clinical and cost utilization based on 70,274 member-months over a 7-year period demonstrated decreases of 60.2% in-hospital admissions, 59.0% less hospital days, 62.0% less outpatient surgeries and procedures, and 85% less pharmaceutical costs when compared with conventional medicine IPA performance for the same health maintenance organization product in the same geography and time frame.
CONCLUSIONS: During the past 7 years, and with a larger population than originally reported, the CAM-oriented PCPs using a nonsurgical/nonpharmaceutical approach demonstrated reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone. Decreased utilization was uniformly achieved by all CAM-oriented PCPs, regardless of their licensure. The validity and generalizability of this observation are guarded given the lack of randomization, lack of statistical analysis possible, and potentially biased data in this population.
From the Full-Text Article:
The utilization of services and the resulting cost outcomes are key variables in health care research. An issue within the complementary and alternative medicine (CAM) realm is whether CAM practitioners are capable of treating a multitude of disorders and, if so, whether the utilization and cost implications are higher or lower than those of conventional health care providers. In this article, we are not taking a position on the efficacy of any CAM treatment. Rather, we are interested in the current use of CAM modalities and cost effects of such use, regardless of treatment outcome. These clinical utilization and cost outcomes are compared with previously published results.
In our previous article, we reported the 4-year clinical utilization and cost outcomes data observed by Alternative Medicine Integration's (AMI's) Integrative Medicine Independent Physicians Association (IPA) in Metropolitan Chicago.  Our analysis of the IPA's clinical utilization and cost outcomes of 21743 member-months over a 4-year period reported utilization reductions of 43% in-hospital admissions, 58.4% hospital days, 43.2% outpatient surgeries and procedures, and 51.8% pharmaceutical costs when compared with conventional medical IPA utilization for the same health maintenance organization (HMO) product in the same geography and same time frame. That report concluded that members enrolled with chiropractic primary care physicians (PCPs) had less standard managed care clinical utilization and cost benchmarks than those members who were enrolled with conventional PCPs using conventional medicine therapies alone.1 The original report analyzed utilization data from the years 1999 through 2002. The intent of this publication is to update the IPA's clinical utilization and cost outcomes observed within the subsequent 3 years, from 2003 through 2005.
Of interest is
(1) whether the observed correlation of decreased utilization remained consistent now that enrollment has more than doubled and the IPA's panel of PCPs includes nonchiropractic CAM-oriented medical doctors and osteopathic doctors (DOs);
(2) how the addition of nonchiropractic PCPs effects the demographics of the enrolled population; and
(3) whether there are any obvious differences in the utilization patterns of enrolled members between the chiropractic PCPs and the nonchiropractic PCPs.
The original publication reviewed in great detail the roadmap for the development and implementation of the IPA, including physician recruitment, provider credentialing, member recruitment and demographics, and IPA medical management strategies. The purpose of this article is to compare and contrast these variables between the 2 periods of data collection. 
Although it is not valid to make the assumption that the predictive vs actual utilization of medical expenditures is an accurate generalized measure of treatment efficacy, it is interesting to note that the utilization data are substantially lower during both eras of 1999 to 2002 and 2003 to 2005. This gives credence to the argument that the power to achieve reduced utilization is due to the underlying philosophy of medical management and not due to differences in PCP education or licensure. It would be interesting to know the normative ratio of predicted vs actual utilization of these relative cost value units for the HMO network as a whole, but this information is unavailable.
The escalation of medical expenditures remains an urgent problem. Conventional medical strategies for clinical improvement and cost containment are failing to achieve their target goals. [8-13] Many patients, looking for improved outcomes, commonly use CAM therapies mixed with conventional medical care without the oversight of a physician specializing in integrative medicine. The safety, efficacy, and cost effectiveness of this unsupervised concomitant use are unknown at this time. However, this study makes the observation that over a 7-year period, the cost outcomes of the integrative medicine IPA are below those of the conventional medical IPAs contracted with the HMO and that, concomitantly, the member satisfaction scores are higher than the conventional medical IPA's.
Along with the single targeted question on patient satisfaction, the HMO's independent quality control division analyzed approximately 50 other questions on the annual member survey to determine if a given IPA achieves “blue ribbon status.” The AMI's IPA has achieved blue ribbon status every year since its inception. In the AMI model, the annual onsite audit scores measuring IPA compliance with the HMO utilization management policies and procedures continue to be above the HMO network normative values. The AMI's annual audit scores in the years 2002-2005 for medical administration and medical management were between 97% and 100% in each category. The HMO minimum required score for IPA performance is 90%. This observation may demonstrate that it is possible to deliver CAM-oriented primary care in a highly regulated environment without compromising either quality or safety.
There are several limitations within this study. First, it is a limitation of the methodology that the data available to us did not allow for a regression analysis. Our analysis of utilization data was unfortunately limited to descriptive comparisons between the identified populations as subsets of the entire HMO population. As the necessary data for traditional statistical methods were unavailable to us, we attempted to assess possible population bias via other strategies. We acknowledge that the lack of statistical analysis may have led to a serious bias. However, even without the ability to complete a statistical analysis and with the potential for bias, these preliminary data are important to present within the medical community. Likewise, attempted statistical analysis might have implied results beyond the methodological capacity of this study. Second, this article is an observational report and does not claim to report causal outcomes but rather the continued long-term observational correlation in decreased utilization seen by enrolled members of an integrative medical model. It is one of the few medical models where concomitant use of both conventional and CAM-oriented treatments is supervised by a licensed health care professional with expertise in both arenas. Third, based on the methods of this study, there is some question about scientific reproducibility. A randomized clinical trial would be necessary to determine if the alternative medicine IPA had a different utilization rate and cost outcome than the conventional IPA. Finally, we were not able to control for differences in baseline characteristics between the integrative medicine group and the conventional IPA. If the baseline demographic or clinical factors differed between the groups, the data may be seriously biased in either direction.
In its effort to improve outcomes, the lay public continues to increase its CAM-oriented utilization; and CAM providers of all licensures continue to slowly gain acceptance within the conventional medical arena. It is clear, however, that not all CAM therapies are efficacious for all disease states. [14-16] Although a blinded, randomized controlled trial isolating individual CAM therapies targeting individual disease states is beyond the scope of this endeavor, it is of great interest that the correlation of decreased utilization of standard managed care benchmarks is seen across the board for the variety of medical conditions reported in the IPA's enrolled population.
Early results from AMI's Integrated Therapies Demonstration Project, a utilization and cost analysis study for the treatment of chronic pain produced for the Florida Agency of Health Care Administration, suggest that the integrative medical strategies, which are the core component of AMI's medical management, seem to be generalizable to other populations, such as Medicaid/Medipass and targeted disease states in a more classic disease management model.
Although the generalizability of such observations is always in question, the IPA model presented here is correlated with a decrease in clinical utilization and cost outcomes, compared with conventional medical strategies, over an extended period and in a safe and highly regulated environment. The consistent decrease in cost and care utilization achieved by AMI's integrative medical management strategy over a 7-year time frame warrants larger independent third-party funding for multicenter, randomized controlled trials.
Practical Applications of This Article:
Members enrolled with chiropractic PCPs have demonstrated lower utilization of clinical and cost benchmarks than members enrolled with conventional medical PCPs.
The variables of age/sex/disease profiles and lifestyle choices were monitored to account for any sample bias when comparing utilization outcomes.
Chiropractic PCPs over a 7-year period have managed 60% of their enrolled members without requiring a referral.