Matthew Holt

Musings on Integrating Care at the IOM

Matthew HoltSo I’m in
DC figuring out how the East coast medical policy elite tries to change the world. While the rest of DC is buzzing about Obama’s speech and budget, The Institute of Medicine is having a conference on Integrative Medicine. But most people think it should be called integrative health. 

What is integrative health, you ask? Good question.

The majority of the panelists are mainstream health care players like Bill Novelli (AARP), George Halvorson, (Kaiser Permanente), Ralph Snyderman, (Duke). They’re talking about integrating coordinated allopathic health care and information across an individual’s personal health plan. Snyderman, said we need to move from “find it, fix it” to a “personal health plan”. Halvorson said (surprise, surprise) that we need electronic health data on every patient, and to not just replicate the current silos of care in our new data strategy. Novelli went straight at the environmental factors—smoking, fast food et al. And to not ignore them.  Mehmet Oz (he of the Oprah show) said that

But many of those I’m seeing in the audience don’t think about that aspect of integrative care. Almost all of them are from the world of “complementary and alternative” medicine. There was little on the stage about integrating east and western medicine together, other than a letter read from Prince Charles, whose Foundation is helping to fund this. He’s very interested in complementary care, but also suggested that we need better outcomes studies for all types of care.

But in the break-out room about health reform (hosted by Arnie Milstein & Larry Lewin) a raft of people specializing in all varieties of complementary care got up and basically said that CMS should pay for what they’re doing. And we heard a lot about “integrating” alternative/CAM care into the system, by getting it into education, changing the CPT codes et al. Arnie Milstein had two questions back 1) Why hadn’t CAM use increased in pay-for-performance in California if it was so effective at improving patient outcomes. And oh so diplomatically he asked, 2) why should we pay for more junk medical care that doesn’t work. (Not his words, of course, Arnie is way too diplomatic for that!) but he did relate it to disease management and a bunch of other programs that don’t seem to work and whose backers think CMS and the taxpayer should cough up.

Back on the main stage we went back to the  integrated vs. integrative muddle. Arnie Milstein found that no big integrated delivery system reduced cost by 15%, but 5 primary care groups did. They were either primary care groups that focus on chronic care (similar to the Ed Waggoner Chronic Care model, and Ed was on the podium describing it) OR they had hospitalists leading teams to identify patients before things went wrong and help follow ambulatory care nurses. All models reduce the number of health crises per patient per year, and reduce the cost per contact, and they did that by really convincing the patients that it mattered to them (the provider) that they didn’t have a health crisis and that got the patient involved. They also referred only to high quality, low cost specialists.

Tracey Graudet from Duke Integrative Care said that our problem is that we’re starting from the wrong place. Health behavior changes are only sustainable if they have significance for the person making the change, but no aspect of the current system is designed to help people make these changes. So she suggests changing the history & physical based on complaints, instead let’s do a whole person medical record. Tracey says we can do this without tearing down the health care system and starting again. Ha, ha! Of course if we replace heart surgery with prevention, we will be putting a lot of interventional cardiologists on the street. There were lots of allusions to how Dean Ornish has shown that you can prove “CAM” therapies are a real and effective alternative to highly invasive mainstream therapies. But it’s been a long road for Ornish, and more importantly, that’s not an easy lifestyle for anyone to adopt.

Mike Magee says that we have to center this back to the home. What’s the missing application? A “lifespan planning record” which takes in individual and envinromental data automatically and creates a participatory strategic health plan, with lots of inputs and outputs and course corrections. I think Mike is right and that companies like Keas are starting to build those tools.

But overall there’s been far far too much about all the great things we can do with integrative care, and nowhere near enough about blowing up the current system incentives that prevent its use. The final question in the last session was telling. It asked, what were the successes and challenges of the organizations in the Braverman network, a demonstration network of integrated care centers including the one at Duke. (Braverman is a philanthropic group in Minneapolis that co-funded this conference with the IOM) The answer was that the challenge was “staying in business”.

More to come on this, as I report on Don Berwick’s excellent summary talk. By the way, the reason I’m in DC is to talk to the NCVHS Full Committee meeting about Health 2.0. More details and I think a live webcast are here.

5 replies »

  1. This is amazing. I attended the 2009 Summit on Integrative Medicine and Health of the Public Matt describes here. I looked around for several weeks after that for any media coverage of what was an astonishing event and found nil. Now here almost 5 years later I stumble onto Matt’s report. The one place I didn’t expect to see anything back then!

    Much has changed in the 4+years since. Integrative Medicine has become a much more substantial component of the healthcare enterprise, in medical education, in inter-professional education, and in the growing science behind the once rebuked components of the complementary class of therapies, acupuncture leading them, yoga and meditation and massage on the track behind it. The inclusion of integrative therapies in the burgeoning health coaching and mentoring community (see Duke Integrative Medicine). The US military’s resolute use of safe therapies that are effective — irrespective of what the skeptics still have to say.

    For me all this has little to do with “selling” a therapy or medical system (like Ayurvedic from India). It is the public telling the medical world — and whoever is part of it — that they want (we want) access to the broadest measure of affordable, least invasive, safe, evidence-informed, clinically proven and compassionately delivered medicine. Period. Integrative medicine docs will tell you that is the plan, to include and balance all the therapies, tools, and techniques available, even some for which the patient does not yet have reimbursement.

    These are often referred to as “high touch, low tech” approaches to care, particularly for dealing with chronic conditions. The challenge I saw in 2009 was how could the Health 2.0 community develop the technologies that reinforce this high-touch quality that is central in integrative medicine (to say nothing of being preferred by patients). How will we lash together big data, personalization and community for very personalized approaches to care that serves the “whole person” at every clinical encounter? These questions remain, so far as I can see.

  2. Thanks for the comment, Mathew. Since that IOM meeting, we’ve continued to make progress with the Lifespan Planning Record concept. This fall we will release the LPR Simulator Experience (first at Emory), a CPE accredited tool that allows health professionals to function as health planners and health coaches for two newborns – one born in 2010, the other in 2025 – and “look forward” 120 years. I created the simulator because I believe that providing health care in a truly preventive system is so different from where we are now that it becomes necessary to “experience it” in order to “get it”. These formative/transformative steps I hope will hopefully implant new concepts and a passion to build them out.

    Mike Magee

  3. Using physicians as managers for patient access to 2.1 million health professionals who are legally authorized to manage care without oversight could bring immediate reductions to health care spending while providing patients with more care. Why? HHS does not offer codes or infrastructure to automate insurance reimbursement to million of health professionals like advanced practice nurses, behavioral health providers, midwives, pharmacists, CAM practitioners and other professions legally authorized to managed non-acute care. These professions are typically paid less than physicians. Instead, HHS mandates use of medical codes jointly developed by CMS and the AMA used to process health care claims and payments and to measure health care outcomes. Without data on care provided by 2.1 million health professions, we are only measuring outcomes from physicians and options to this care are invisible to the industry.

  4. Bradley. I honestly think that the CAM types who proposed the meeting hoped that the integrated systems types would talk about them how to get acupuncture/massage reimbursed by Medicare. Which is not what they said….

  5. “But many of those I’m seeing in the audience don’t think about that aspect of integrative care. Almost all of them are from the world of “complementary and alternative” medicine.”
    Somehow, I am not surprised. Matthew, can you elaborate a bit more on the CAM vs PCMH-oid type camps as I am not sure I know the distinction of “integrative” at this point based on your lengthy post. Do folks who are into biofeedback and yoga give a hoot about HIT, chronic care coordination, etc.? This seems like an interesting mix of folks, especially with the likes of docs like Arnie Milstein, and I am wondering if the sunni and the shia are playing nice togther.