Clinical and Cost Outcomes of an
Integrative Medicine IPA

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

FROM:   J Manipulative Physiol Ther 2004 (Jun) ;   27 (5):   336–347

Sarnat RL, Winterstein J

Alternative Medicine Integration Group, LP, Highland Park, IL 60035, USA. rsarnat@amibestmed.com

OBJECTIVE:   We hypothesized that primary care physicians (PCPs) specializing in a nonpharmaceutical/nonsurgical approach as their primary modality and utilizing a variety of complementary/alternative medicine (CAM) techniques integrated with allopathic medicine would have superior clinical and cost outcomes compared with PCPs utilizing conventional medicine alone.

DESIGN:   Incurred claims and stratified randomized patient surveys were analyzed for clinical outcomes, cost offsets, and member satisfaction compared with normative values. Comparative blinded data, using nonrandomized matched comparison groups, was analyzed for age/sex demographics and disease profiles to examine sample bias.

SETTING:   An integrative medicine independent provider association (IPA) contracted with a National Committee for Quality Assurance (NCQA)-accredited health maintenance organization (HMO) in metropolitan Chicago.

SUBJECTS:   All members enrolled with the integrative medicine IPA from January 1, 1999 through December 31, 2002.

RESULTS:   Analysis of clinical and cost outcomes on 21,743 member months over a 4-year period demonstrated decreases of 43.0% in hospital admissions per 1000, 58.4% hospital days per 1000, 43.2% outpatient surgeries and procedures per 1000, and 51.8% pharmaceutical cost reductions when compared with normative conventional medicine IPA performance for the same HMO product in the same geography over the same time frame.

CONCLUSIONS:   In the limited population studied, PCPs utilizing an integrative medical approach emphasizing a variety of CAM therapies had substantially improved clinical outcomes and cost offsets compared with PCPs utilizing conventional medicine alone. While certainly promising, these initial results may not be consistent on a larger and more diverse population.


From the Full-Text Article:

DISCUSSION:

Certainly, we now appreciate the importance of lifestyle and environmental factors in the optimization of health and subsequent prevention of disease. Reliance on the conventional medical model, in which pharmaceuticals and surgical interventions represent first-line treatment, may not provide the best therapeutic index to our patients. The AMI model seems to demonstrate the potential superiority of an integrated health system in which chiropractic and CAM therapies play a significant primary care role.

Traditional PCPs, be they MDs or DOs, have little formal training in the various evidence-based techniques within the CAM arena. Doctors of Chiropractic, however, receive extensive formal training in the arts of spinal manipulation, herbal medicine, and nutrition, as well as conventional modern physical diagnosis. Most of the AMI PCPs electively received additional postgraduate training in homeopathy, TCM, and other CAM modalities. Students of chiropractic learn to auscultate heart and lungs, draw blood, and read electrocardiograms (EKGs), as well as perform pelvic and rectal exams. However, the educational focus and scope of practice laws vary among chiropractic colleges and states, respectively.

It is incumbent on the primary care physician, of whatever licensure, to look at all evidence-based risk factors and seek to coordinate their reduction. Most of the time this will involve the re-education of patients regarding lifestyle choices such as diet, exercise, nutrition, supplementation, correction of posture, and stress management issues. Lifestyle re-education emphasizing prevention and wellness may be best addressed by PCPs with an unconventional medical orientation, as opposed to conventional medical physicians who have been educated and focus primarily on disease management. The AMI experience seems to indicate that a nonpharmaceutical/nonsurgical orientation can reduce overall health care costs significantly and yet deliver high-quality care. These results have been achieved not by decreasing or denying access to care but, rather, by increasing the frequency of PCP prevention-oriented encounters.

The chiropractic profession is the largest stakeholder in the ongoing evolution of integrating CAM therapies into mainstream conventional medicine. Doctors of Chiropractic are licensed in all states, compared with Doctors of Naturopathy licensed in 11 states and Doctors of Oriental Medicine licensed in only 5 states. Acupuncturists and massage therapists are licensed in 40 and 30 states, respectively. Chiropractic is the most commonly utilized CAM therapy, as published in many previous surveys. Yet, paradoxically, core coverage by insurance benefit design rarely includes unrestricted access to chiropractic. Instead, a myriad of excuses both by the private insurance industry and by the federal government currently reduce one's personal freedom by restricting access to choose unconventional medicine, even when practiced by licensed physicians in good standing. Various authors believe the restrictions on covered benefits for CAM therapies and unconventional physicians are indefensible, given the growing evidence base on these therapies. [51]

“Discount affinity programs” promoted as a “value added” service are currently the most common insurance format by which CAM therapies are available. In reality, these programs are not covered insurance benefits at all. They do not place the mainstream insurance underwriter at financial risk. Rather, they provide the insured with a discount off market fee-for-service rates for severely restricted pseudo benefits. [52] The American Chiropractic Association (ACA), the largest professional association representing the largest stakeholder to the delivery of CAM therapies, has formally rejected discount affinity programs as an insurance sham. [53]

While the availability of discount affinity programs gives the public the illusion that CAM therapies are a covered service on par with conventional medicine, that is not the case. The AMI Wellness Model, by contrast, has been formally recognized by both the ACA and the American Academy of Chiropractic Physicians as a future template of an integrated medical model, which is “front-end loaded” to address prevention and wellness. An increase in initial PCP services is required by the patient to re-educate and emphasize the modification of inappropriate lifestyle choices, thereby re-empowering the patient toward improved self-determination. The good news is that within a 3- to 4-month time period, much of the behavior responsible for the etiology of new or chronic disease has been modified. The initial investment of time, energy, and financial resources for CAM therapies has been successful, apparently much more successful than a quick pharmaceutical prescription and a hasty visit with a conventional PCP (typical of the way managed care is practiced today).

Recently published literature also suggests patient preference and increased satisfaction with integrative therapies for chronic disease states. In the articles by Eisenberg et al [54-56] comparing patients' subjective perceptions as to the relative value of conventional care versus CAM therapies, in only 3 of 10 therapies was conventional medicine perceived as superior to CAM therapies. The 3 disease states scoring higher for conventional medicine were high blood pressure, lung conditions, and digestive conditions. By contrast, back conditions, allergies, fatigue, arthritis, headaches, neck conditions, and strains and sprains were perceived better treated by CAM therapies. [54-56] AMI's higher percentage of members with ICD-9 codes for orthopedics, mental health, chronic sinus, allergy, gastrointestinal problems, and headaches versus the comparison group enrollment is consistent with this pattern.

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