Health Systems

Charles Elder, MD Clinical Investigator at Kaiser Permanente Center for Health Research, NWP

Integrating CAM Into Practice: The KP Northwest Story

Introduction

As a general internist with an interest in CAM, I find it exciting to be at Kaiser Permanente (KP), because our group is at the cutting edge of integrating CAM with conventional care. We have a great story to tell! In this discussion, I will paint a broad picture for you of what we are doing in the KP Northwest Region (KPNW) in the area of complementary and alternative medicine (CAM). As we go along, you should be thinking, as an individual practitioner, about how you can begin to actively integrate evidence-based CAM into your practice. As we, both as individuals and as an organization, gain increasing proficiency at doing this, the care experience for patients as well as for practitioners will proportionally improve.

First, I will talk about why we are interested in CAM in the first place. Then, against that backdrop, we will look at what is happening in the Pacific Northwest. I will describe the networks of CAM providers to whom we refer our patients, how we make those referrals, and under what circumstances. Next, I will review several ongoing projects that introduce CAM practice within our own medical offices. Finally, we will talk about the Oregon Center for Complementary and Alternative Medicine Research, an NIH-funded CAM research center based at the KP Center for Health Research (in Portland, OR). When we have concluded, I think you will all clearly understand that we have a great story to tell. You should also gain at least a few practical ideas for integrating CAM that you can then take right back to your practice.

Background of the CAM Movement

What is behind the CAM movement? Why do we even care about CAM in the first place? I'll describe four forces that are propelling this phenomenon forward: medical utilization, competitive pressures, physician practice patterns, and legislative mandates. Regarding medical utilization, I refer to a study published by Eisenberg and colleagues in the New England Journal of Medicine in 1993.¹ The authors of that paper conducted a national telephone survey of 1539 adults to ask about details of their CAM use. Approximately one third of respondents reported use of at least one CAM modality during the preceding 12 months.¹ When the survey was repeated four years later, in 1997 (with the data published in JAMA in 1998),² the 34% figure had increased to 42%! The data suggest that CAM use is widely prevalent among patients and that, far from representing a fad, this use is increasing.

Another figure illustrates the competitive pressures which this use of CAM generates. In 1998, Landmark Health Care Corporation conducted a national telephone survey of consumers to ask them how much importance they attach to CAM coverage when selecting a health plan.³ Thirty-one percent of respondents answered that CAM coverage is very important, 36% responded that it is somewhat important, and 33% said that it is not important.³ We thus conclude that CAM use among patients is high and that for about two thirds of patients, CAM coverage is a consideration when purchasing health insurance. These two phenomena play an important role in propelling CAM onto the health care agenda.

Physician practice patterns represent another important consideration. In a study by Gordon and Sobel published in The Permanente Journal in 1999,⁴ the investigators mailed a survey to all primary care clinicians and a subset of the obstetrics and gynecology clinicians in the KP Northern California Region (KPNC) and received approximately 800 responses. Approximately 70% of clinicians who responded were somewhat or very interested in having better CAM availability for their practices. These clinicians were then asked to explain why they wanted this improved access to CAM. Although "growing patient demand" and the need for KP to "remain competitive" were cited as important reasons, these were not the most popular answers; the two main reasons given by KPNC clinicians for wanting improved CAM access were that 1) patients are seen for problems that cannot be adequately treated with more conventional methods and that 2) the clinicians believed that many health problems can be more effectively treated by using a mind/body or holistic approach than with a more conventional, Western approach.⁴

That most of the KP clinicians responding to the survey wanted better CAM access is important--but not
surprising. What is fascinating, however, is that the main reasons relate not to patient demand or to competitive pressures but to self-perceived shortcomings in our own conventional clinical paradigm. A pressing need to expand the armamentarium of the primary care clinician thus represents another major force driving the CAM phenomenon forward.

In addition to patient demand, competitive pressures, and physician practice patterns, legislative mandates represent a fourth important factor in the equation. In the state of Washington, the "any category of provider" statute was enacted in 1995. With approximately one third of our health plan membership residing in Washington state, efforts to comply with this law have had a substantial impact on operations in the KPNW. Succinctly stated, the law mandates that health insurance companies doing business in the state of Washington must provide coverage for clinically indicated health care services provided by any category of provider for which there is a licensing body in the state. In other words, because Washington awards licenses to acupuncturists, chiropractors, and naturopaths, KP's health plan must cover those services when clinically indicated. Along with patient demand, competitive pressures, and physician practice patterns, the "any category of provider" statute has played a substantial role in shaping our approach to CAM at KPNW.

What KPNW is Doing to Meet the Challenges of CAM

Having a clear sense of why we are interested in CAM, we can now discuss efforts underway at KPNW to meet this challenge. First, we have established relationships with local networks of CAM providers to provide services on a referral basis for our patients when these services are clinically indicated. For acupuncture, referrals to an Acumed network provider can be approved only for Washington members in the setting of chronic pain or for nausea and vomiting associated with either cancer chemotherapy or pregnancy. These referral guidelines are based in large part on the NIH consensus statement on acupuncture, which, though released in 1997, nonetheless represents an excellent synopsis of the evidence base.⁵ Currently, we approve one or two acupuncture referrals a week.

Chiropractic care is similarly available to most members on a referral basis through the Chironet network. Accepted indications for referral are acute nonradicular back or neck pain only, for which most patient referrals are approved for a total of approximately six visits. KPNW is using this Chironet referral mechanism with
sufficient frequency that the possibility of providing limited chiropractic services as an internal service is being considered. For naturopathic services, we similarly contract with a network called Naturenet. Historically, referral has been indicated for women with perimenopausal symptoms in whom hormone replacement therapy has failed or is contraindicated; currently, these guidelines are under review. In practice, KPNW approves approximately two or three referrals per month for naturopathic care.

In addition to referral-generated consultations, some of our members' employers purchase a product that allows the patient to self-refer to CAM providers. Substantial copayments and other limitations apply, and patients who select this plan are obligated to select from among the network providers.

Although most of the CAM care provided by KPNW to our members is delivered through these affiliated networks, several efforts through the KP primary care, pharmacy, health education, and other departments offer members access to CAM services at our own medical offices. As one example, KPNW offers an internal, referral-based group integrative medicine clinic. The rationale inspiring the clinic stems from well-known improvements in communication, quality, and cost, which can be achieved by maintaining an internal referral service (ie, versus an outside referral service). In addition, the clinic introduces further efficiency by using the cooperative health care clinic model.⁶ Staffed by a primary care physician and a nurse, the group clinic is open to any member who is interested in a holistic model of care and who is referred by another clinician for treatment of a subacute or chronic medical condition. The two-hour group session is mostly didactic and encompasses dietary, behavioral, herbal, and other modalities that are based on a Vedic medicine paradigm.⁷ After attending the group session, most patients follow up with an individual return visit. Member survey data suggest excellent patient satisfaction as well as excellent self-reported outcomes for patients attending this clinic.⁸

The KPNW Regional Pharmacy Committee has appointed a natural products subcommittee charged with educating members and clinicians about herbal supplements and with evaluating supplements for potential inclusion in the over-the-counter shelves of KP pharmacies. The committee conducts evidence reviews of popular herbal extracts and is responsible for identifying appropriate suppliers with good manufacturing practices. We expect that some supplements, such as glucosamine sulfate, saw palmetto, ginkgo, and St John's wort may be available to members at KPNW pharmacies in the near future.

The KPNW Health Education Department has several CAM-related offerings for members. These offerings include a women's health education series (with some lectures led by naturopathic physicians) and a class on managing stress and anxiety that teaches breathing, visualization, and relaxation techniques as well as a number of other stress management tools. In addition to these programs, numerous individual KPNW clinicians provide integrated care in a number of ways. For example, both hypnosis and healing touch are offered by trained clinicians at our regional pain clinic. Several osteopathic physicians in KPNW do spinal manipulation, and a dentist at our Temporomandibular Disorders (TMD) Clinic offers neurofeedback.

In addition to these clinical activities, KPNW is active in the areas of both CAM education and research. The KP Center for Health Research has been designated one of about 16 NIH-funded CAM research centers in the country. Known as the Oregon Center for Complementary and Alternative Medicine Research (OCCAM), the consortium includes investigators and clinicians from KP, from the Oregon Health & Science University, and from four CAM colleges located in the Portland metropolitan area. OCCAM is currently conducting three large phase II clinical trials and also provides funds for smaller developmental projects, all focusing on evaluating CAM interventions in the setting of craniofacial disease. In addition to these research projects, OCCAM offers research fellowships to help train clinicians as CAM clinical researchers. Several KPNW clinicians have been awarded funding by OCCAM, both for fellowship training and for developmental research.

In cooperation with OCCAM, KPNW sponsors a quarterly CAM journal club that provides a forum for continuing education in the area of CAM research as well as opportunities for discussion and networking among members of the KP community interested in CAM. These dinner meetings generally last about two hours and are attended by a broad range of health care professionals, including physicians, nurse practitioners, CAM providers, clinical investigators, pharmacists, nurses, and others.

Conclusions

This impressive array of activities shows that KP is in a leading position to support, at both practitioner and system levels, integration of evidence-based CAM into routine practice. The history of our group is one of
bold and farsighted innovation, and it is incumbent upon us to provide strong leadership on this issue. Individual clinicians can educate themselves to provide accurate information about CAM to patients, to refer patients to CAM providers when this is indicated, and to recommend herbal extracts for appropriate purposes. In addition, some KP clinicians have received CME training in CAM systems and modalities. Both patient and clinician satisfaction with the care experience stand to dramatically improve as we move forward with this work.

References

1. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med 1993 Jan 28;328(4):246-52.
2. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998 Nov 11;280(18):1569-75.
3. Landmark Healthcare. The Landmark report on public perceptions of alternative care: selected findings [Web site]. Available from: www.landmarkhealthcare.com/98tlrI.htm (accessed September 26, 2002).
4. Gordon NP, Sobel DS. Use of and interest in complementary and alternative therapies among clinicians and adult members of the Kaiser Permanente Northern California Region: results of a 1996 survey. Perm J 1999 Summer;3(2):44-55.
5. Acupuncture. NIH Consens Statement 1997 Nov 3-5;15(5):1-34.
6. Beck A, Scott J, Williams P, et al. A randomized trial of group outpatient visits for chronically ill older HMO members: the Cooperative Health Care Clinic. J Am Geriatr Soc 1997 May;45(5)543-9.
7. Sharma HM, Clark C. Contemporary Ayurveda: medicine and research in Maharishi Ayur-Veda. New York: Churchill Livingston; 1998.
8. Elder C. Application of group outpatient visit model for the delivery of integrative medicine at a health maintenance organization. Presented at the 2nd International Conference on Complementary, Alternative and Integrative Medicine, Boston, MA, April 12-14, 2002.
   
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