From acupuncture to naturopathy
Patients-and money-compelling doctors to look at alternative medicine
By Jennifer Fisher Wilson
General internist Matthew M. Hine, MD, MPH, usually meets with new patients for an hour and a half before deciding whether to prescribe conventional medicine, like antibiotics, or an alternative, like chelation therapy or botanical supplements, or a combination of the two. When patients need to be referred, he does so—either to a traditional medical specialist or to a reputable healer, such as a licensed acupuncturist, depending on the patient's needs.
|Illustration by Michael McGurl||Dr. Hine said his mix of conventional and alternative medicine ensures that standards are high. "Medical doctors have a responsibility to guide patient care responsibly. Otherwise, people not as well-qualified, unlicensed 'healers,' will take over their care," he said. Plus, offering alternative options keeps his patients happy and his solo practice in Colorado Springs, Colo., thriving.
Despite continuing skepticism in most of the medical community, some doctors are beginning to shape successful practices-from just talking about alternativetherapies to actually hiring related staff such as reflexologists-around the philosophies of both alternative and conventional medicine, said David M. Eisenberg, MD, one of nation's leading researchers into America's use of unconventional medicine. Even though most health plans don't cover alternative therapies beyond chiropractic and acupuncture treatments, they are increasingly looking to cover a wider range of alternative care. And patients often desire these alternatives enough to pay for them out of pocket.
|For example, Dr. Hine gets reimbursed for some alternative therapy by American Western Life Insurance, a preferred provider organization with a wellness plan that offers members holistic options for care. He said many of his patients with other coverage pay out of pocket for the unconventional therapy.
Patients' willingness to pay can be compelling. One internist in Birmingham, Ala., for example, has gone from practicing conventional medicine full-time to practicing alternative medicine "95% of the time." Even though most of his patients have to pay for his services themselves, his practice is more successful than ever. "I've got to be doing something right," said Gus J. Prosch Jr., MD. He said that he evaluates good medicine not on whether he learned it from medical school or medical journals, but on the basis of whether his experience has shown that it is safe and it works.
Although he is licensed by the state, members of the medical community have challenged his practice's efficacy and safety. Because so much of what he does is unconventional medicine, the state medical board has ordered Dr. Prosch to practice in conjunction with his patients' primary care physicians. For example, one of his patients with lung cancer started treatments with him, including a diet designed to boost her immune system, while also undergoing chemotherapy and radiation with her traditional physician. "They told her she had two years to live, but now it's two years later and she's healthy," Dr. Prosch said. Of conventional doctors, he said: "they treat the symptoms and I treat the cause." Together, he believes that their work saves lives.
While experts say one in three patients has reportedly embraced alternative medicine to some extent, most internists remain skeptical-as many in medicine would argue they rightly should. "There's a real lack of useful information about the safety, toxicity, cost-effectiveness and effectiveness of alternative therapies," Dr. Eisenberg said. Without solid information, doctors are hard-pressed to give advice or information about alternative therapies, he said, let alone expand their practices to include such therapies.
"We ought to be practicing evidence-based medicine as much as possible. We should be practicing medicine that works, and that is that," said Walter J. McDonald, FACP, the College's Executive Vice President.
The College's Ethics Manual suggests that physicians should talk with patients seeking alternative medical care. Physicians should be sure patients understand their condition and standard medical treatment options and find out why patients are seeking alternatives. The physician should not abandon patients who try alternative treatments, but should approach their decision with compassion, according to the manual.
"The saying 'first do no harm' is what has to be done and said to our patients. And if what is being done by alternative therapists is potentially harmful, if a delay is engendered, we have an obligation to explain that to our patients," Dr. McDonald said. "At other times it does no harm, and even if it does no good for the patient physically, it may make them feel better. And then we may be able to back off."
Until just a few years ago, alternative medicine was just about invisible to much of the American medical establishment. But when the Jan. 28, 1993, New England Journal of Medicine (NEJM) reported that Americans visit alternative therapy practitioners more often than their medical doctors, spending about $13.7 billion on the unconventional therapies a year (three-fourths of it out of pocket), the medical world began to pay attention.
"A whole different system of general medicine is going on that most physicians are unaware of," said Richard Honsinger Jr., FACP, an allergist in Los Alamos, N.M. "If you ask about it, at least one out of three people are using some alternative therapy."
Partly in response to the NEJM report, the National Institutes of Health formed the Office of Alternative Medicine and funded 10 research centers at university medical centers. Harvard University founded the Center for Alternative Medicine; Columbia University now has the Richard and Hinda Rosenthal Center for Complementary and Alternative Medicine and Georgetown University has the Center for Mind-Body Medicine. The University of Virginia School of Medicine mandated an alternative medicine course for all medical students, while about 30 medical schools nationwide added elective seminars and survey courses on alternative medicine, which they call everything from unconventional to unproved to complementary medicine. Such medicine is typically defined as interventions not taught widely in U.S. medical schools. Included are chiropractic techniques, massage, relaxation, imagery, spiritual healing, lifestyle diets, herbal medicine, energy healing and homeopathy.
A handful of health insurance companies also responded to the NEJM data and started including coverage for alternative therapies in their plans. Besides American Western Life, Presbyterian Health Plan of New Mexico offers members access to alternative care through a point-of-service plan by covering it on an out-of-plan basis. After members pay the deductible for going out-of-plan, Presbyterian shares the cost of alternative treatments with them. Therapists may only bill for procedures performed within the scope of their practice.
For its patients in New York, New Jersey and Connecticut, Oxford Health Plans Inc. takes coverage a step further through a policy rider available to their subscribers that covers visits to therapists within the plan's alternative providers network-credentialed acupuncturists, massage therapists, chiropractors, registered dietitians, clinical nutritionists, yoga instructors and, in Connecticut, naturopathy physicians. Acupuncturists, chiropractors and naturopaths must have state licensure, specialty certification, a site evaluation, and a minimum of two consecutive years of clinical experience and continuing education courses. To access these providers, patients contribute a small co-pay and don't need a referral from a primary care physician.
A number of plans cover alternative care for specific conditions. Boston's Harvard Pilgrim Health Plan and Group Health Cooperative of Puget Sound in Seattle have offered coverage for alternative lower back pain therapies. Mutual of Omaha covers a wellness plan alternative to surgery for heart disease. Sharp Health Plan offers subscribers a wellness course in ayurvedic healing designed by Deepak Chopra.
"Where will the money come from for this coverage?" asked Dr. Honsinger. In this era of cost-cutting, it's likely that health plans will expect general physicians to share health care dollars with alternative therapists, he said.
But the insurance companies like Oxford and Presbyterian see it differently. By choosing to react to their members' demands for alternative therapies, they are tapping into a multi-billion dollar market. In a recent survey by Oxford, a third of its 1.4 million members reported that they had used alternative health care in the last year. So while extending traditional coverage incurs added expense, the insurance companies expect to offset that by increased membership and partly by increased costs to members. Employers currently using Oxford HMOs pay about 3% more to access its alternative providers network.
Insurance companies might even save money by allowing patients to see alternative therapists because the procedures often use low-technology treatments compared to conventional physicians, according to Dr. Eisenberg. In the future, an integrated approach between alternative and traditional medicine might be in the patient's best interest and actually reduce costs, he said.
Currently, most patients double costs by seeing their regular doctor and alternative therapists at the same time. New Mexico allergist Dr. Honsinger finds that many of his allergy patients are taking herbs or using alternative therapies, often in conjunction but not in coordination with medication from their physicians. Dr. Honsinger practices only conventional medicine, and so he rarely communicates with the alternative therapists his patients see. But he worries about possible interactions between the drugs he prescribes and the herbal remedies his patients may take.
Many of his patients profess to believe in unproved therapies as much as, or more than, conventional medicine even when he can offer them scientifically tested and proven treatments. "I'm not going to stop this patient belief system, but I don't have to accept it," he said.
But other internists have decided that, proven or not, it is time to get a piece of the action or risk losing business. Some practices have hired a reflexologist or a masseuse to perform and bill for reflexology or massage therapy in the office. Physicians within the Presbyterian Health Plan based in Albuquerque, N.M., may suggest alternative therapy if all allopathic treatment approaches have been exhausted, or if the primary physician sees that the only other option is trying more expensive procedures or hospitalization, said Karen Smoot, Presbyterian's director of provider relations. Also, the plan will usually cover visits to alternative therapists "if a member wants to go to them," she said.
Other physicians, like Dr. Hine and Dr. Prosch, have chosen to perform-and charge for-alternative therapies themselves.
"There are dual-trained physician-acupuncturists and doctor-homeopaths providing allopathic and alternative care," said Dr. Eisenberg, an assistant professor at Harvard Medical School and director of the Center for Alternative Medicine Research at Beth Israel-Deaconess Medical Center.
The physicians who provide alternative care have taught themselves to use the unconventional therapies or taken continuing education courses sponsored by holistic, homeopathic, naturopathic or acupuncture associations.
Plus, others are looking into formalizing the process. For example, Andrew Weil, MD, a professor at the Arizona Center for Health and Medicine at the University of Arizona, has developed a program in integrated medicine where allopathic medical doctors train as alternative therapists by adding two years of education in unconventional care. Dr. Weil also has a popular World Wide Web home page that mixes prevention and alternative medicine tips with conventional medicine advice. For mononucleosis, for example, he recommends echinacea, a product from the root of the purple coneflower and astragalus membranceous, a relative of locoweed, in addition to fluids, rest and non-aspirin pain reliever. (For more details, see Dr. Weil's home page, Ask Dr. Weil at http://www.drweil.com.)
Most internists, however, are still at the point of thinking about whether to even talk openly with their patients about alternative therapies. A reasonable strategy for dealing with patients who use both allopathic and alternative medicine needs to be developed, experts agree. "We really need to work with these patients, to be a partner with them in fighting disease, not their adversary," Dr. Honsinger said.
Many internists are taking the approach of Gail Povar, FACP, of Bethesda, Md. Dr. Povar does not offer her patients alternative care, but she openly talks with them about their use of alternative therapy and does not generally discourage its use unless it poses a danger to their health. "It may make them feel better," she said.
Dr. Eisenberg believes that physicians should do just that--focus on their conventional practice of medicine, but have an understanding of what else is going on in medicine, too. "It's absolutely inevitable that physicians are going to have to face alternative medicine," he said.
The best thing physicians can do, then, is to increase patients' understanding of alternative medicine, he said, and be proponents of research on the topic. "In doing this," Dr. Eisenberg explained, "the physician advocates for the patient and for the reasonable practice of medicine."
Alternative therapy education
For a list of alternative medicine electives offered at medical schools nationwide, visit the Rosenthal Center for Complementary & Alternative Medicine at http://cpmc.net.columbia.edu/dept/rosenthal.
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