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.