J Altern Complement Med. 2017 (Nov); 23 (11): 837–843 ~ FULL TEXT
Patricia M. Herman, ND, PhD, Melony E. Sorbero, PhD,
and Ann C. Sims-Columbia, BSN, MHA, MBA, FACHE
Santa Monica, CA.
OBJECTIVES: Surveys of military personnel indicate substantial use of complementary and alternative medicine (CAM) that possibly exceeds use in the general U.S.
POPULATION: Although military treatment facilities (MTFs) are known to offer CAM, surveys do not indicate where service members receive this care. This study offers a comprehensive system-wide accounting of the types of CAM offered across the military health system (MHS), the conditions for which it is used, and its level of use. These data will help MHS policymakers better support their population's healthcare needs.
DESIGN: A census survey of MTFs across the MHS on all CAM use, supplemented where possible by MHS utilization data.
OUTCOME MEASURES: Types of CAM offered by each MTF, reasons given for offering CAM, health conditions for which CAM is used, and number of patient visits for each CAM type.
RESULTS: Of the 142 MTFs in the MHS, 133 (94%) responded. Of these, 110 (83%) offer at least one type of CAM and 5 more plan to offer CAM services in the future. Larger military treatment facilities (MTFs) (those reporting ≥25,000 beneficiaries enrolled) are both more likely to offer CAM services (p < 0.001) and a larger number (>10) of different types of CAM (p = 0.010) than smaller MTFs. Three-fourths of MTFs offering CAM provide stress management/relaxation therapy, two-thirds provide acupuncture, and at least half provide progressive muscle relaxation, guided imagery, chiropractic, and mindfulness meditation. MTFs most commonly report CAM use for pain and mental health conditions. Acupuncture and chiropractic are most commonly used for pain, and stress management/relaxation therapy and mind-body medicine combinations are most often used for mental health-related conditions. We estimate 76,000 CAM patient encounters per month across the MHS.
CONCLUSIONS: The availability of CAM services in the MHS is widespread and is being used to address a range of challenging pain and mental health conditions.
KEYWORDS: complementary therapies; military; military health system; military treatment facilities; service members
From the FULL TEXT Article:
The U.S. military health system (MHS) is one of the
largest in the world with a budget of $51.5 billion in
fiscal year 2016 and 9.4 million eligible beneficiaries, including
active duty and reserve service members, and retirees,
and their families.  A number of studies have indicated
that many in the military use complementary and alternative
medicine (CAM) — aka, complementary and integrative health
approaches. [2–10] While approximately one-third of adults in
the United States report use of some form of CAM in the past
12 months,  several studies have shown that CAM use may be
even higher among military personnel. [2, 4–6, 8–10] According to
one review, any CAM use in military populations ranges between
37% and 46% among nonpatient populations and up to
72% in patient populations.  The higher rates in these patient
samples may be, in part, because CAM users report more illness
and poorer health in general. [3–5]
CAM is utilized for a wide variety of physical and psychologic
conditions, as well as for general improvement of
health and well-being. [12, 13] A study based on a national sample
of the U.S. population indicates that the 15 most common
conditions for which CAM is used are back pain, neck pain,
joint pain, arthritis, anxiety, cholesterol, head or chest cold,
other musculoskeletal, severe headache or migraine, insomnia
or trouble sleeping, stress, stomach or intestinal illness,
depression, and regular headaches.  However, few studies
of CAM use in the military indicate the conditions for which
these therapies are used.  One survey asking about CAM
use  and an analysis of MHS utilization data  support that
CAM is used in military patient populations for similar
conditions as seen in the general U.S. population, although
possibly not in the same proportions.
Over time, CAM service offerings at military treatment
facilities (MTFs) have increased. Interviews with the Deputy
Chief of Clinical Services or service equivalent in 14
selected MTFs in 2005 and 2009 revealed substantial increases
in the number of providers delivering CAM, number
of MTFs offering different types of CAM, and the types
of CAM services offered.  The rate of service members
who received one of three types of CAM (acupuncture,
biofeedback, and chiropractic or osteopathic manipulation)
within the MHS also more than doubled between 2010 and
The use of CAM is also being incorporated into the MHS’s
clinical practice guidelines. For example, the current Department
of Veterans Affairs (VA)/Department of Defense
(DoD) clinical practice guidelines for posttraumatic stress
disorder and major depressive disorder recommends selected
CAM modalities as an adjunct, or as an alternative, to first-line
treatments. [16, 17] In addition, the VA/DoD clinical practice
guidelines for low-back pain also recommend a number of
CAM modalities, especially for those with chronic pain and
for those who do not improve with self-care. 
Surveys that report CAM use in military populations
generally do not distinguish between CAM received at
MTFs versus that obtained through self-care or from
community practitioners. For the MHS to respond to the
needs of its service members, it must not only understand
the extent of CAM use in its patient population overall but
also the extent of CAM services already offered in its
MTFs. This census of CAM in the MTFs provides the first
comprehensive picture of the full range of CAM therapies
offered in MTFs across the MHS, the conditions for which
CAM is used, and estimates of the number of patient visits
for these services.
Materials and Methods
Our study utilizes two data sources: an online survey of
CAM services offered in each MTF and a supplemental
analysis of MHS healthcare utilization data. We obtained
human subjects research protection approval from RAND’s
Human Subjects Protection Committee and the USAMRMC
Human Research Protections Office for both components
of this study. The CAM survey also received approval for
internal DoD data collection from the Washington Headquarters
Services. More detail on the study design, patient
demand and adherence, combinations of CAM offered,
provider types and their credentialing and privileging, documentation
in the medical record, and recommendations for
the MHS can be found in the full RAND report. 
The CAM survey
The MHS CAM survey was adapted from the 2011
Veterans Health Administration CAM Survey, an instrument
used to capture information about the provision of
CAM services in the VA in 2011.  To enable comparison
with the results of the VA CAM survey, many of the items
in the MHS survey replicate the exact wording from the
VA survey. The survey asked about 31 types of CAM,
included a glossary with definitions of each type, and allowed
respondents to also write in other types of CAM
The study was designed to be a census of MTFs and
included all Air Force, Army, National Capital Region
Medical Directorate, and Navy and Marine Corps MTFs.
The Assistant Secretary of Defense for Health Affairs
tasked the Assistant Secretaries of Manpower and Reserve
Affairs in each service branch with circulating the data
request to all the MTFs under their purview. Therefore, the
Surgeons General of each service identified all their MTFs
for a total of 142.
To minimize data entry burden and better reflect the way
services are delivered in practice, respondents were allowed
to group CAM therapies that tended to be used together by
the same practitioner for the same conditions. Respondents
then answered certain of the CAM service-specific questions
for their defined combination(s) rather than for each of the
Use of CAM services in MHS utilization data
For comparison and to give context to the CAM survey
data, we extracted healthcare utilization data from the
MHS Data Repository, which is managed and maintained
by the Defense Health Agency. Our dataset contained
healthcare utilization for fiscal years 2008 through 2013
for all active military and activated Guard and Reserve
component service members across all MTFs separated
into files containing outpatient and inpatient healthcare
provided at MTFs and outpatient and inpatient healthcare
purchased outside of MTFs. These data capture the five
types of CAM for which current procedural terminology
(CPT) codes exist: acupuncture, biofeedback, chiropractic,
hypnosis, and massage.
To describe CAM services offered at MTFs and characteristics
of specific services, we computed univariate frequency
distributions and percentages using R and Microsoft
The survey was fielded from August through October
2015. The response rate was high: 133* of 142 MTFs (94%)
completed the survey. There was also minimal item
nonresponse: fewer than 5% of MTFs had missing data on
any given survey item.
CAM offered in MTFs
Out of the 133 MTFs responding to the survey, 83% of
MTFs (N = 110) offer CAM services to their patients, 14%
(N = 18) do not, and an additional 4% (N= 5) currently do
not offer them, but are planning to offer CAM services in
the future. Six of the 23 MTFs that do not currently offer
CAM services recommend or refer patients to these services
outside the MHS.
Most of the MTFs without CAM and no plans to offer
CAM (n = 18) cite lack of provider availability and proficiency
(78%) as the reason why. Few (3 or fewer) noted lack
of patient interest, patient unwillingness, or worries about
safety or efficacy of CAM as reasons.
Of the 115 MTFs that currently offer or plan to offer
CAM, more than half endorsed one or more of five reasons
for providing CAM:
(1) as adjunctive to chronic disease management (91 MTFs or 79%);
(2) to fulfill patient preference (84 MTFs or 73%);
(3) to promote wellness (82 MTFs or 71%);
(4) because of proven clinical effectiveness (78 MTFs or 68%); and
(5) to fulfill provider request (66 MTFs or 57%).
Half (n = 57) of MTFs report offering CAM because it promotes cost savings to the MTF.
Of the 110 MTFs that offer CAM, nine offer only one
type of CAM and two-thirds (73 MTFs) offer two to eight
different types of CAM. Six MTFs have extensive CAM
offerings with 20–22 different types of CAM available.
In general, larger MTFs (those reporting more beneficiaries
enrolled) are both more likely to offer CAM services
and a larger number of different types of CAM. MTFs reporting
at least 25,000 beneficiaries are significantly more
likely to both offer CAM (p < 0.001) and more than 10
different types of CAM (p = 0.01) than MTFs reporting
fewer than 25,000 beneficiaries. Army MTFs are also significantly
more likely than Air Force MTFs to offer more
than 10 types of CAM (p = 0.001). However, no other statistically
significant differences in the offer of CAM or in
the number of types of CAM offered were found.
Among the MTFs offering CAM services (N = 110),
three-fourths offer stress management/relaxation therapy
and approximately two-thirds offer acupuncture (Table 1).
At least half of these MTFs offer progressive muscle relaxation,
guided imagery, chiropractic services, and mindfulness
meditation. Although included in the survey
instrument, none of the MTFs reported offering Ayurveda,
chelation therapy, homeopathy, Native American healing
practices, or naturopathic medicine.
Providers may offer combinations of CAM services to treat
a single condition. Each type of CAM service was reported as
being used in combination with other CAM services by at
least one MTF and as being used alone by at least two MTFs.
Note that MTFs could report separately on a CAM service’s
use alone and as part of one or more combinations of CAM
Examination of the MHS utilization data show that the
overall use of the five CAM therapies with CPT codes
(acupuncture, biofeedback, chiropractic, hypnosis and massage)
has increased on average 10% per year over the 2008–
2013 period with massage increasing at a slower rate than the
others. Almost all CAM use documented in the MHS utilization
data occurs in the MTF on an outpatient basis. CAM
services are rarely (0.01%) provided in the inpatient setting,
and less than 3% of outpatient use occurs outside the MTFs
(i.e., purchased care). Most service members receiving purchased
CAM care live 40 miles or more from an MTF.
The columns in Table 2 present the 10 most common
conditions for which CAM is used across MTFs. For each
condition, we also present the CAM services most commonly
reported by MTFs as being used to treat it. With one
exception (general health/wellness/prevention), the conditions
represent a combination of pain and behavioral/mental
MHS utilization data indicate that nearly 90% of visits for
the five CAM services with CPT codes are for chronic musculoskeletal
pain. This proportion by CAM type is over 90%
for chiropractic and massage and is 62% for acupuncture. In
contrast, about two-thirds (65%) of hypnosis and 40% of
biofeedback visits are for psychologic health conditions.
We assessed the frequency of patient visits for CAM
services in MTFs by asking in the survey for an estimate of
the number of patient encounters per month for each CAM
service offered in MTFs. Respondents were asked to select
one of the following categories: fewer than 50; 51–100; 101–
150; 151–200; 201–500; ormore than 500. There is substantial
variation—both across type of CAMand across MTFs—in the
monthly number of patient encounters in which these CAM
services are used alone (Figure 1). For example, about two-thirds
of MTFs offering acupuncture, stress management/relaxation
therapy, progressive muscle relaxation, biofeedback, and
acupressure reported fewer than 50 patient encounters per
month for these services. In contrast, only 10% of MTFs offering
chiropractic reported fewer than 50 patient encounters
permonth and almost 20% reported more than 500 chiropractic
patient encounters per month. In addition, MTFs reported 17
different combinations of CAM services with more than 500
patient encounters per month.
Assigning a midpoint number to each of the patient encounter
categories assessed (and using 750 for more than
500) and summing these numbers across all MTFs that offer
that type of CAM service result in a total estimated number
of patient encounters of almost 76,000 (range using low-end
and top-end numbers, respectively: 45,500–106,000) per
month. Utilization varies widely by type of CAM service.
For example, chiropractic and mind-body medicine combinations
have the highest estimated number of encounters
(both >10,000/month); aromatherapy (25/month) and herbal
medicines (50/month) are among the CAM services with the
lowest estimated number of encounters.
According to MHS utilization data, chiropractic is by far
the most frequently used of the five CAM services recorded
in these data, followed by acupuncture and massage (Table 3).
Assuming all procedures for one patient on one day equals
a visit; the number of procedures by CAM type is roughly
equivalent to the number of patient visits, except for acupuncture.
On average, providers recorded 1.67 acupuncture procedures
per visit, possibly indicating that about two-thirds of the
visits for acupuncture went beyond the 15 min allowed on the
first CPT code to also require the subsequent 15–min code. The
second-to-last column in Table 3 shows that on average, patients
using these five CAMservices receive three to six visits per year.
To determine the reasonableness of the MTF estimates of
patient encounters per month and our translation of those
into total patient encounters, the last column of Table 3
shows estimated patient encounters from the CAM survey,
which can be compared to the second column showing
2013 outpatient MTF-based visits from the MHS utilization
The data shown in Table 3 allow us to determine the proportion
of total outpatient care delivered in the MTFs that
CAM represents. The five CAM procedures shown in Table 3
comprise 1% of all procedures across allMTFs and 2%of total
visits. One out of every 25 patients (4%) with any outpatient
care at the MTF in fiscal year 2013 received at least one of
these five CAM services.
The sum of the patient encounter estimates for the five
CAM services shown in Table 3 comprises *30% (24,400/
76,000) of patient encounters across all CAM types. If we
assume that the 408,847 visits for the fiveCAMservices shown
in Table 3 make up 30% of all CAM visits, we can estimate
total CAMvisits at 1,362,823 (408,847/0.30). Therefore,CAM
visits are estimated to make up *7% (1,362,823/18,885,329)
of total outpatient MTF visits.
We provide the first system-wide look at the CAM services
offered in the MHS. CAM services are widespread:
83% of MTFs offer one or more type of CAM service for a
variety of conditions, many of which can be difficult to treat
with conventional medicine, such as chronic pain, stress,
anxiety, and sleep disturbance. With *76,000 patient visits
per month, CAM services represent a small, but nontrivial
portion of total outpatient MTF visits (*7%). However,
there are barriers to the provision of CAM in MTFs. MTFs
cite not having the necessary providers as the most common
reason for not offering CAM.
In general, our study’s findings about CAM in MTFs are
consistent with results of the VA’s CAM surveys conducted
in 2011 and 2015. [20, 21] Similarities include the percentage of
facilities offering CAM, the number of CAM types offered
at each facility, reasons for offering and not offering CAM,
the main conditions for which these treatments are used,
and the general number of estimated patient encounters per
month. There are, of course, also differences between the
studies. The VA tends to have more facilities that offer, and
more estimated patient encounters for, animal-assisted
therapy, biofeedback, and music therapy, and fewer facilities
that offer acupuncture (although the estimated number
of patient encounters is similar) than the MHS.
As was shown in recent analyses of MHS utilization
data,  we also found that the use of CAM with CPT codes
increased over time and similar conditions for which these
therapies are used. We cannot, however, match their 2013
utilization numbers because they used a smaller sample. The
Williams et al. study was based on those who served in the
active component of the military (n = 1,538,209 in 2013),
while we also included the activated Guard and Reserve
component (n = 1,919,676 in 2013).
Our study documents the offer of CAM services within
the MHS. Surveys of individuals’ CAM use rarely indicate
where the respondent received their care. Our data in
Table 3 can be used to determine that 2.9% (55,843/1,919,676)
of servicemembers who receive care in theMHS had visits for
chiropractic in 2013 and 0.8% had visits for massage. These
figures are substantially below the percentages who report use
of these CAM services in surveys of individuals.  In 2005,
5.2% of a large global active-duty military nonpatient sample
reported using chiropractic and 14.1% reported using massage.
2 This indicates that service members likely obtain most
of their CAM use outside the MHS.
A major strength of this study is that it is based on data
obtained from two sources. However, we are aware of the
limitations inherent in both. Survey respondents reported
that they obtained the requested information by talking to
individual CAM providers, staff in behavioral/mental health
and primary care, and other healthcare providers. In MTFs
that offer just a small number of CAM services, it is likely
that a single individual or small group of people have adequate
knowledge to accurately answer the survey. However,
larger MTFs with numerous clinics may provide CAM
services of which the MTF respondent and their informants
were unaware, and they together may not have sufficiently
comprehensive knowledge of the CAM services provided to
accurately answer all the questions in the CAM survey. We
are grateful for their efforts, but have made recommendations
for more formal and consistent system-wide data collection
procedures for the future.
The healthcare utilization data that we used to supplement
the CAM survey also have limitations. Specific procedure
codes are only available for five general types of
CAM: acupuncture, biofeedback, chiropractic, hypnosis/
hypnotherapy, and massage therapy. Therefore, analyses
based on the MHS utilization data could address only these
Nevertheless, both data sources bring their strengths to
this study. The utilization data report on the use of procedures,
which can be applied to estimate numbers of patients
and visits; in contrast, the CAM survey reports activities at
an MTF level. Thus, while the survey indicated that acupuncture
is offered at a larger number of MTFs (69%) than
chiropractic (55%), MHS utilization data indicate that more
chiropractic procedures are delivered per year.
Using two data sources also allowed us to compare estimates
of CAM patient visits from each source for the five
types of CAM available in the utilization data. Through this
comparison, we determined that the survey estimates of use
seem reasonable, especially since we would not expect the
figures to exactly match for several reasons. First, the MHS
utilization data are for fiscal year 2013 and the CAM survey
was fielded in 2015. Second, the survey numbers could be
lower because patient encounters for a portion of these
CAM therapies could have been counted in the estimates
given for the CAM combinations defined by respondents.
The mixed combinations group was itself estimated to account
for a total of 11,350 patient encounters per month
(i.e., 136,200/year), and 8 of the 10 mixed combinations
with more than 500 patient visits per month included massage.
Third, the mid-point numbers we used to represent
each category of patient encounters may not be good estimates
of actual utilization, especially for the top and bottom
categories. For example, chiropractic encounters were estimated
at more than 500 per month at nine MTFs. Our estimate
based on 750 (or even 1000) patient encounters per
month for these MTFs could be much too low.
CAM represents an important part of the management of
some challenging conditions within the MHS. Our comprehensive
assessment of CAM services offered in MTFs
makes a substantial contribution to ongoing efforts to understand
the role and availability of CAM to better inform
policies related to its provision and use. Information from
this study can be used by MTFs to enhance and streamline
their services to meet demands and contain costs.
This study was funded by the Defense Center of Excellence
for Psychological Health and Traumatic Brain
Injury (DCoE). We gratefully acknowledge the support of
our project officers and points of contact at DCoE, and our
points of contact for each of the service branches, and we
are particularly grateful for the time and effort of the MTF
staff who gathered and submitted data on their MTFs and
made this study possible.
Author Disclosure Statement
No competing financial interests exist.
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