legal status of traditional and complementary/alternative medicine in In some countries, the legal standing of complementary/alternative medicine is …
CLINICAL AND COST OUTCOMES OF AN INTEGRATIVE MEDICINE IPA
Richard L Sarnat, MD,a and James Winterstein, DC b
ABSTRACT
Objective: We hypothesized that primary care physicians PCPs specializing in a nonpharmaceutical/nonsurgical approach as their primary modality and utilizing a variety of complementary/alternative medicine CAM techniques integrated with allopathic medicine would have superior clinical and cost outcomes compared with PCPs utilizing conventional medicine alone Design: Incurred claims and stratified randomized patient surveys were analyzed for clinical outcomes, cost offsets, and member satisfaction compared with normative values Comparative blinded data, using nonrandomized matched comparison groups, was analyzed for age/sex demographics and disease profiles to examine sample bias Setting: An integrative medicine independent provider association IPA contracted with a National Committee for
Quality Assurance NCQA-accredited health maintenance organization HMO in
metropolitan Chicago
Subjects: All members enrolled with the integrative medicine IPA from January 1, 1999 through December 31, 2002 Results: Analysis of clinical and cost outcomes on 21,743 member months over a 4-year period demonstrated decreases
of 430 in hospital admissions per 1000, 584 hospital days per 1000, 432 outpatient surgeries and procedures per 1000, and 518 pharmaceutical cost reductions when compared with normative conventional medicine IPA performance for the same HMO product in the same geography over the same time frame
Conclusion: In the limited population studied, PCPs utilizing an integrative medical approach emphasizing a variety
of CAM therapies had substantially improved clinical outcomes and cost offsets compared with PCPs utilizing conventional medicine alone While certainly promising, these initial results may not be consistent on a larger and more diverse population J Manipulative Physiol Ther 2004;27:336-47
Key Indexing Terms: CAM Therapy; Medicine;
Outcomes; Primary Care Physician; Managed Care
INTRODUCTION
T
he escalation of medical expenditures is an urgent problem Although various types of managed care, once thought by some to be part of the solution to increasing medical expenditures, have been used for decades, little evidence exists that this or any other costcontainment strategy has significantly influenced a 50-year trend of increasing medical expenses on a long-term basis1-5 Managed care rates are now posting double-digit
a President, Alternative Medicine Integration Group, LP, Highland Park, Ill b President, National University of Health Sciences, Lombard, Ill Submit requests for reprints to: Richard L Sarnat, MD, President, Alternative Medicine Integration Group, LP, 473 Central Avenue, Suite 2, Highland Park, IL 60035 e-mail: rsarnat@ amibestmedcom Paper submitted November 12, 2003 0161-4754/3000 Copyright n 2004 by National University of Health Sciences doi:101016/jjmpt200404007
annual increases,6 with
pharmaceuticals estimated to account for 50 of the cost increases over the past 3 years7 While the health care system excels in acute care and crisis disease state management, this accounts for only a small percentage of the total medical care in both cost and volume rendered daily8 The greater health care burden is the prevention and treatment of the multiple chronic disorders in the general population that now account for the majority of health care expenditures9 Chronic diseases are a major public problem in the United States Currently, about 40 of the US population approximately 100 million Americans suffer from at least 1 chronic disorder9 This high level of prevalence within the United States raises concerns about the efficacy and limitations of our conventional health care system10 Such concerns appear to contribute to public and professional interest in alternatives to conventional modern medicine Studies now suggest that 50 of the deaths11 and 70 of the diseases12 in the
United States are caused by unhealthy lifestyle habits such as smoking, alcohol abuse, and improper diet Unlike the preantibiotic era when mortality was
336
Journal of Manipulative and Physiological Therapeutics Volume 27, Number 5
Sarnat and Winterstein Integrated Medical IPA
337
primarily because of infectious diseases, our nation now faces a behavior-induced epidemic of chronic illness Managed care and government policy makers are faced with the dilemma of trying to decrease medical costs caused mainly by lifestyle choices while continuing to maintain personal freedom of choice Iatrogenic illness an adverse condition arising from the treatment of a physician is estimated as the etiology of 15 of our hospital days, and pharmaceuticals are estimated to cause between 100,000 to 250,000 deaths per year,13,14 as well as nonquantifiable morbidity Prescription drug addiction, administering the wrong drug, and prescription overdoses are a large percentage15,16 of reported deaths by
medical mistake The National Conference of State Legislatures, November/December 2000, estimates the cost of lost income, disability, and health care resulting from medical mistakes is as much as 29 billion per year17 Given these facts, it may be time to rethink this countrys current medical model with its overall reliance on pharmaceuticals as a first line option Complementary/alternative medicine is one viable approach that should be considered because it addresses the privacy, quality, and expense considerations facing health care delivery systems Unlike conventional medical education and care, which relies heavily on high technology and pharmaceuticals, complementary/alternative medicine exists in a low-tech arena Low-tech therapeutic modalities such as chiropractic manipulation, homeopathy, stress management, massage, and use of herbal medicines are perceived by the public as more gentle, less morbid, and less costly than conventional modern medicine18 Many previous studies on
various complementary/alternative medicine CAM modalities have illustrated improved clinical outcomes and substantially decreased costs compared with standard conventional medical practice protocols19-44 However, while individual diagnostic categories have been analyzed, a study of the clinical outcomes and cost effectiveness of primary care physicians PCPs specializing in CAM, and more particularly chiropractic care, within the context of a classical gatekeeper health maintenance organization HMO has never previously been attempted
outpatient surgery and procedures This information was collected prospectively over a 4-year period The HMO actuarial department prepared an annual financial projection for the IPA membership as an age/sex riskadjusted population On a cost basis, the discrepancies between the projected costs versus the actual costs were analyzed annually Standard managed care benchmarks, including hospital days per 1000, hospital admissions per 1000, outpatient surgeries
and procedures per 1000, and pharmaceutical utilization were reported annually by the HMO normative network values and then compared with the actual utilization of the integrative medicine IPA Randomized patient surveys were conducted annually by the HMO to assess member satisfaction, quality of care benchmarks, and member behavior patterns eg, tobacco usage
Integrative Medicine IPA-Development and Implementation
In 1996, a large HMO accredited by the National Committee for Quality Assurance NCQA servicing the metropolitan Chicago area was initially contacted to test the feasibility of gathering data on a CAM-oriented health care delivery system This HMO was a classical gatekeeper HMO with over 600,000 members enrolled in the greater Chicago area The projects objective was to build an integrated medicine system in the Chicago metropolitan area that would use primary care physicians who specialize in a nonpharmaceutical/nonsurgical approach as their primary modality These
nonpharmaceutically oriented PCPs, notably chiropractic physicians, were organized into a well-defined structure along with their more conventional allopathic counterparts to create a truly integrated health care system encompassing both CAM therapies and conventional modern medicine within a single comprehensive insurance benefit structure The project was designed for a gatekeeper HMO format because its structure simplified data collection and made mandatory reporting a contractual obligation To test this new model, an alternative medicine IPA, legally incorporated in 1997 as Alternative Medicine, Inc AMI, was formed to function within the classical gatekeeper HMO format under the same rules and regulations as any other contracted conventional allopathic IPA The data reported herein refer to the contractual relationship between AMI as an integrative medicine IPA and the specific HMO unless otherwise noted The formation of an IPA under contract with the HMO required specific
contractual elements to be met according to the National Committee for Quality Assurance The minimum requirements for PCP network support included: Contracted availability of all allopathic specialists Contractual relationships with regional hospitals to provide inpatient access
METHODS
Data reported in this study were drawn from incurred claims data, originating from both the integrative medicine independent provider association IPA and the HMO The IPA data included all inpatient and outpatient encounters for both cost and diagnosis, including the professional fees associated with patient referrals, outpatient diagnostics encounters and costs, and outpatient laboratories encounters and costs The HMO data included the encounters and costs of all pharmaceutical usage, inpatient admissions, and
338
Sarnat and Winterstein Integrated Medical IPA
Journal of Manipulative and Physiological Therapeutics June 2004
A minimum roster of both pediatricians and obstetricians/gynecologists
exclusive to the IPA HMO Peer Review Committee approval of the IPAs utilization management UM and utilization review UR plan policy and procedures As reported later in section IV, Medical Management, each of these prerequisites was successfully addressed prior to PCP impanelment All primary care physicians had to pass credentialing by the Credentialing Peer Review Committee of the HMO, which was composed of medical doctors MDs exclusively For a new IPA to be impaneled, every PCP needed to successfully pass the credentialing criteria A single failure would have prohibited the project from initiation Initial analysis identified 4 separate and independent but related processes that needed to occur to provide the foundation for successful execution: 1 Physician Recruitment: Targeting that subset of physicians who would be appropriate PCPs to function in a nonpharmaceutical/nonsurgical model In this study, only chiropractic physicians agreed to participate as PCPs 2 Credentialing Process:
Developing a credentialing process exceeding the existing NCQA requirements for CAM providers, a standardized process to quantify the performance of this subset of prospective primary care physicians according to accepted industry standards 3 Member Recruitment: Addressing the ability to recruit potential members or patients to test the hypothesis that primary care chiropractic physicians specializing in nonpharmaceutical/nonsurgical approaches as their primary modality and using CAM techniques integrated with allopathic medicine would have superior clinical and cost outcomes compared with PCPs utilizing conventional medicine alone4 4 Medical Management: Formalizing the medical management to provide integrated care between the CAM therapies delivered by the chiropractic physicians and other conventional medical specialists throughout the inpatient/outpatient cycle The following sections address the mechanics of how each element was defined and executed to successfully achieve the
outcomes reported herein Physician recruitment Nonpharmaceutical/nonsurgical physicians were defined to include those physicians who use as their primary diagnostic/treatment modalities such disciplines as chiropractic manipulation, osteopathic manipulation, naturopathy, homeopathy, Traditional Chinese Medicine TCM, acupuncture, Ayurvedic medicine, herbal medicine preference over pharmaceuticals, massage, and energy healing techniques Under the Medical Practice Act and Managed Care Act, the State of Illinois only licenses medical doctors, Doctors of Osteopathy DO, and Doctors of Chiropractic DC as primary care physicians Therefore, Doctors of Naturopa-
thy ND and Doctors of Oriental Medicine OMD, although licensed in other states, were automatically excluded from the IPA physician network At the projects inception, personal interviews were conducted with all categories of physicians, including MDs/DOs and DCs whose style of medical practice qualified them as potential CAM-oriented
PCPs For a variety of professional, personal, political, and economic reasons, only the Doctors of Chiropractic were willing to undertake the project All CAM-oriented MDs/DOs interviewed rejected participation for reasons including too restrictive a reimbursement model, philosophical or political issues with managed care in general, inability to meet credentialing requirements because of lack of board certification, or independent lone ranger personality, not comfortable with third-party oversight and review Credentialing process Since, to our knowledge, Doctors of Chiropractic had previously never served as PCPs in a classical gatekeeper HMO model, this presented an immediate credentialing challenge A unique credentialing process was developed to identify that subset of Doctors of Chiropractic who could successfully function as PCPs Each prospective PCP underwent a personal interview to review his or her treatment modalities, criterion for referrals, and comfort in dealing with a
primary care role Preference was given for such qualities as broad scope of practice patterns, history of appropriate interactions with other medical specialists, and demonstrated understanding of the pathophysiologic basis of disease as currently understood by evidence-based Western medicine This process has now been formalized into a standardized test and is currently offered as provisional credentialing to students at the National University of Health Sciences in Lombard, Illinois, as well as endorsed by the American Academy of Chiropractic Physicians AACP The credentialing process also involved an educational component, including seminars given by AMI MD medical directors to review conventional medicine diagnostic and referral decision trees Registered nurses provided the onsite component where prospective physicians and their office staff received training in Health Employer Data and Information Set HEDIS compliance, Occupational Safety Health Administration OSHA compliance, and
instruction in proper charting requirements Time spent in the onsite component varied between 4 hours and 20 hours to achieve successful completion All primary care chiropractic physicians were held accountable to the same criteria as their MD/DO counterparts under NCQA regulations It is important to note the educational training of the chiropractic physician While similar in many regards to medical training, there is no training in surgical procedures or in the use of drugs in the management of human illness The standard course of training is in excess of 4800 hours, with approximately one quarter spent in the clinical setting Course work encompasses programs in standard
Journal of Manipulative and Physiological Therapeutics Volume 27, Number 5
Sarnat and Winterstein Integrated Medical IPA
339
diagnosis ie, cardiovascular diagnosis, neurological diagnosis, gastrointestinal diagnosis, genitourinary diagnosis, etc, as well as more specifically chiropractic programs ie, manipulation
of the spine and extremities, physiotherapeutic modalities and other forms of CAM ie, homeopathy, herbal therapy, botanical medicine, etc45,46 The HMO Peer Review Committee formally approved all of AMIs primary care chiropractic physicians in the fall of 1998 AMI began patient encounters on January 1, 1999 with 16 fully credentialed primary care chiropractic physicians As of December 31, 2002, AMI had 30 primary care chiropractic physicians in the HMO model Member recruitment The HMO under contract had an enrollment of over 600,000 members and was available only to companies with a minimum employee base of 100 enrollees AMIs prospective members originated from open enrollment offered to the total population of the HMO Most members obtained information about AMI from the HMOs standard primary care and specialist physician directories or their companys human resource HR personnel The HMO used no marketing incentives to attract potential patient enrollees to the alternative medicine IPA
Like all classical HMOs, there was no exclusion of patients having preexisting illnesses In the first month of operation, January 1, 1999, AMIs HMO had an enrollment of 37 members Enrollment as of December 31, 2002 was 649 members Because marketing had been by word of mouth, growth in IPA enrollment was steady but slow IPA enrollment measured in member months mm per calendar year grew from 1726 mm calendar year 1999 to 4987 mm calendar year 2000, to 6932 mm calendar year 2001, and to 8098 mm calendar year 2002 In total, 21,743 mm of data were analyzed This standard managed care unit is calculated by multiplying each unique member by the number of months enrolled within the IPA during a calendar year The HMO calculates the ratio of new member transfer in versus transfer out for each IPA on a monthly basis AMIs range for transfer in lies between 343 and 553, and transfer out is between 283 and 350 The higher ratio of transfer in versus out correlates with the observed growth in member
enrollment Medical management The intention was to provide members with the best treatment that both chiropractic, using a variety of CAM techniques, and conventional modern medicine had to offer All of the AMI primary care chiropractic physicians focused primarily on the assessment and evaluation of all risk factors whether they were related to diet/nutrition, exercise, postural/structural problems, behavioral/emotional problems, physiological disease, or the need for improved stress management Similar to the role allopathic PCPs assume in a conventional medical IPA, all examinations, treatments, and procedures that occurred within the offices of the primary care chiropractic physicians were at the discretion of the
PCP The number of recommended visits, the choice of appropriate treatments, and ancillary modalities utilized did not require approval from the IPA MD medical directors All ancillary testing and treatment outside the personal office of the primary care chiropractic
physician was subject to MD medical director approval to benefit from the enhanced experience of allopathic physicians in dealing with more complex and varied disease states One inpatient-oriented and 2 outpatient-oriented MD medical directors were available 24 hours a day, 7 days per week to provide consultation and comanagement by phone or facsimile, as required, according to the complexity of the patients presentation Over 3000 medical specialists and 18 hospitals including university based were under contract by AMI as part of the IPA to provide integrated care as appropriate to medical necessity Ongoing telephonic and/or facsimile consultation and comanagement between the PCPs and the MD medical directors occurred daily In general, primary care chiropractic physicians practiced what they do best: nonpharmaceutical/nonsurgical prevention When and if acute life threatening disease or advanced disease management required inpatient status or conventional modern medicine, the PCP
delegated his/her authority to the attending medical physician consulted A registered nurse specializing in utilization management and utilization review coordinated continuity of care between the inpatient and outpatient cycle By design, AMIs PCPs had a higher number of encounters initially to correct structural dysfunctions and provide re-education in lifestyle choices that left unchanged may have manifested into more serious disease states It was not atypical for new AMI members to have PCP encounters at an average of twice per month This is in contrast to conventional medical IPAs, wherein the majority of members have PCP encounters on a crisisonly basis AMIs New Member Welcome letter informed the patient that it was IPA policy to have a mandatory initial visit with their PCP within the first 3 months of enrollment These frequent education-oriented encounters combined with hands-on healing were believed to forge a strong doctor/patient relationship The PCP then became the trusted
guide and assisted the patient with the required lifestyle changes or gave professional advice on the many and varied uses of CAM Many modalities of CAM remain unregulated and are most safely and effectively utilized when supervised by a licensed physician truly knowledgeable from extended training in CAM The chiropractic PCPs also utilized nonphysician CAM providers These providers were licensed and/or credentialed in various CAM therapies, such as massage, acupuncture, cranial sacral therapy, and stress management techniques, including meditation, yoga, and energy balancing, as well as more traditional cognitive therapy It
340
Sarnat and Winterstein Integrated Medical IPA
Journal of Manipulative and Physiological Therapeutics June 2004
Table 1 Diagnostic profile of AMIs HMO population year 2000
Diagnoses Wellness Orthopedic Other medical Mental health Gynecological Sinus/allergy Cardiac/hypertension Headaches all variations Neoplastic URI Asthma Gastrointestinal Thyroid disease
Diabetes Diagnoses by percentage 285 235 117 81 67 60 46 27 15 15 14 13 12 12 100 Diagnoses by members 149 123 61 43 35 31 24 14 8 8 7 7 6 6 522
Table 2 Comparison of well members AMI versus comparison groups I and II
Members with no or non-ICD-9 encounters 149 2618 3206 Percentage of members coded as wellness 285 347 420 Percentage of members coded for active disease 715 653 580
IPA AMI Control group I Control group II
Members enrolled 522 7549 7723
AMI, Alternative Medicine, Inc; IPA, independent provider association
522 members with diagnoses includes 31 severely ill patients multiple ICD-9 comorbidities AMI, Alternative Medicine, Inc; HMO, health maintenance organization; URI, upper respiratory infection Mental health defined as those patients requiring a referral to a mental health specialist
is important to note that the chiropractic physicians included in this study utilized all the modalities noted above and not just the chiropractic adjustment as a sole therapeutic
intervention It was anticipated that this increased intensity in prevention-oriented encounters and concomitant comanagement with AMIs MD medical directors would reduce the utilization of high-cost, high-technology conventional medicine downstream
Member Populations: AMI Versus Nonrandomized Matched Comparison Groups
In this section, Tables 1 through 3 compare various aspects of the AMI membership versus 2 nonrandomized matched comparison groups Both comparison groups represent separate conventional IPA enrollment within the same commercial HMO product, in the same geographic region, and during the same time frame as AMIs data AMI patient population demographics versus comparisons While the comparison groups demographics have been matched as much as possible to remove any underlying bias, certain dissimilarities exist Children, defined as member enrollment under the age of 20, represents a smaller population percentage in the AMI program compared with the comparison groups: 119 AMI
versus 328 comparison group I and 190 comparison group II The smaller percentage of children enrolled is not accidental Chiropractic physicians are unable to legally administer childhood immunizations because of limitations in the scope of prac-
tice of their licensure While AMI does not prohibit enrollment for children under 10, it is not encouraged Statistical analysis also reveals a slightly decreased average age of adult members in the AMI population 395 years compared with comparison groups I 413 years and II 403 years While this slight average age discrepancy certainly favors increased cost expenditures in the comparison groups, this may be offset by the fact that AMI has a greater percentage enrollment of female members compared with male members The actuarial department of the HMO predicts more than a 50 greater utilization within the IPA by female members versus male members The sex distribution of AMI membership is 616 female members and 384 male memers By contrast,
comparison group I had 589 female members and 411 male members; comparison group II had 591 female members and 409 male members The HMO forwarded age/sex distribution data to AMI in the form of monthly eligibility lists Comparison group data were forwarded to the authors from the conventional IPAs after receiving their individualized data from the HMO AMI patient population disease profile AMIs HMO membership, as reported herein, represented a unique population dissimilar from previously published literature of disease states commonly seen by chiropractors47 Chiropractors primarily care for patients with complaints of musculoskeletal origin or headaches As AMI was the first managed care program to utilize chiropractors in a PCP role, it was not surprising that membership included a wide range of disease states not seen in the typical chiropractic office, as illustrated in Table 1 When analyzing IPA data, diagnostic classification was assigned to individual patients based on PCP
encounter data, specialist encounter data, referral activity, and pharmaceutical usage When multiple International Classification of Diseases, Ninth Revision ICD-9 codes were listed on encounter data, the diagnosis requiring the higher expenditure for workup or treatment was chosen as the primary classification If the presence of prominent severe comorbidity such as hypertensive cardiac disease, diabetes
Journal of Manipulative and Physiological Therapeutics Volume 27, Number 5
Sarnat and Winterstein Integrated Medical IPA
341
Table 3 Comparison of ICD-9 diagnostic profile by percentage of member enrollment AMI versus comparison group I
Diagnosis Wellness Orthopedic Other medical Mental health Gyne non-OB Sinus/chronic allergy Cardiac/hypertension Headache all variants Neoplastic all URI Asthma GI Diabetes Thyroid disease all AMI 285 235 117 81 67 60 46 27 15 15 14 13 12 12 Comparison group I 347 80 170 13 94 28 94 07 11 104 13 09 34 14
Table 4 AMI outcomes comparison with HMO
network data
1999 2002
AMI percentage utilization vs HMO Hospital-based data Hospital admissions/1000 Hospital days/1000 Average length of stay Outpatient-based data Outpatient surgical cases/1000 Pharmaceutical usage cost AMI percentage reduction vs HMO
570 416 762 568 482
430 584 238 432 518
AMI, Alternative Medicine, Inc; HMO, health maintenance organization Obstetrics admissions excluded from comparison percentages
AMI, Alternative Medicine, Inc; GYN, gynecology; OB, obstetrics; URI, upper respiratory infection; GI, gastrointestinal
ICD-9 Profile of Nonrandomized Matched Medical Comparison Groups I and II
In this section, Tables 2 and 3 reflect membership breakdown by ICD-9 diagnostic coding percentage comparing AMIs membership with the membership of comparison groups I and II Both comparison groups represent conventional IPA enrollment for the same commercial HMO product in the same geographic region during the same time frame as AMIs data A blinded independent contractor
with previous employment in the medical records department of a local hospital analyzed ICD-9 coding data, compiling the disease profiles between AMIs membership and comparison group I membership Previously published literature indicates that users of CAM modalities are not necessarily the worried well and may actually represent an adverse selection of patients who are medical failures in the traditional medical system48,49 The prevalence of active disease in the AMI population as shown in Tables 2 and 3 is consistent with earlier reports of this phenomena The fact that potentially life-threatening disease states, such as cardiac disease, hypertension, and diabetes had higher enrollment in conventional medicine IPAs was not surprising The similar percentage enrollment of patients with asthma and neoplastic disease between conventional and integrative medicine IPAs was somewhat surprising The large enrollment disparity among patients with upper respiratory infections URI, as previously
mentioned, reflects the small percentage of AMIs enrollment under 10 years of age A comparison of smoker prevalence among the AMI population, the HMO population, and the general state population further demonstrates possible adverse selection in the AMI population Member satisfaction surveys, randomly distributed by stratified random selection to between 35,000 and 45,000 HMO members, annually elicited a response rate that varied between 25 and 30 These
mellitus, and bipolar disorder were all prominent in a patients encounter data, then the patient received 3 separate and distinct classifications This explains why 491 unique patients in the year 2000 received 522 disease classifications Table 1 The diagnostic category wellness referenced in Tables 1 through 3 was defined as: 1 members having patient encounters but not receiving ICD-9 codes these patients may have been symptomatic but received chiropractic codes for subluxation/dysfunction by their PCPs; 2 members having encounters for
nonsymptomatic screening test only; or 3 members having no encounters within a given calendar year The category other medical listed in Table 1 117 of AMIs population encompassed a wide range of diseases affecting 61 patients These diseases included listed in order of frequency but were not limited to the following: neurologic disorders, abdominal pain, dermatologic disorders, prostate disease, adrenal cortical insufficiency, chronic fatigue syndrome, cystitis, esophageal reflux, multiple sclerosis, tinnitus, temporomandibular joint TMJ, and human immunodeficiency virus HIV As Doctors of Chiropractic had not previously functioned as PCPs, the congruence of their diagnoses when compared with conventional PCPs when reporting on a Health Care Financing Administration HCFA 1500 encounter form was unknown When PCP diagnostic coding data were cross-correlated with both specialist referral data and pharmaceutical usage, agreement was found between the conventional medical specialist and the
chiropractic PCP 931 of the time When the diagnosis necessitated a treatment that required the use of pharmaceuticals or surgery, then an appropriate referral was made to a conventional medical specialist
342
Sarnat and Winterstein Integrated Medical IPA
Journal of Manipulative and Physiological Therapeutics June 2004
Table 5 Calendar year 2000 hospital days incurred among major Illinois Managed Care Organizations MCO versus AMI
Total member months 7,537,362 787,853 269,268 361,437 143,236 1,664,525 3,536,085 13,645 Total hospital days incurred per 1000 member months 34485 32002 28538 23675 20100 17764 17094 1150 AMI percentage utilization 333 359 403 486 572 647 673 AMI percentage reductions 667 641 597 514 428 353 327
Managed care entity HMO Illinois Personal Care Insurance Company of Illinois Prudential Health Care Plan United Healthcare of the Midwest CIGNA Healthcare of IL Aetna US Healthcare of IL Humana Health Plan, Inc AMI 3-year cumulative
AMI, Alternative Medicine,
Inc; HMO, health maintenance organization
surveys revealed a variance in the AMI population when measuring for smoker prevalence rate In calendar year 2001, the AMI membership showed its highest rate of smoker prevalence: 349 versus the HMO population rate of 180 versus the Illinois general population of 22350 In calendar year 2003, by contrast, AMI membership had its lowest smoker prevalence rate of 133 versus the HMO population rate of 163 We assume the large variance from year to year was secondary to the relatively low membership response rates elicited by the survey
These statistical benchmarks were reported as a comparison between the performance of AMI as an IPA and the HMO network as a whole Because of the HMOs proprietary concerns regarding their networks unique data points, AMIs outcomes are reported as percentage comparisons with HMO outcomes
RESULTS
Outcomes: Clinical
These data points are based on the HMOs corroborated data for the 4 calendar years 1999, 2000, 2001, and
2002 AMIs encounter data represent 21,743 member months over this 4-year period The traditional managed care benchmarks depicted in Table 4 illustrate AMIs apparent superior clinical outcomes compared with conventional IPA performance over the same time frame AMIs outcomes are reported as percentage utilization and percentage reduction versus the HMO network as a whole Percentage utilization is based on actual claims data after a 6-month runoff comparing AMIs utilization of key benchmarks versus the HMO network as a whole Percentage reduction reflects the mathematical complement of AMIs utilization percentages using the HMO network outcomes as the normative value of 100 Traditional P values of statistical significance could not be reported Insurance actuaries do not currently have data points for variance and mean on groups of similar size and demographics Only aggregate data the HMO normative network performance representing groups of all sizes and demographics were available Calendar
year 2000 data on hospital admission days Table 5 obtained from the Illinois Department of Insurance similarly reflect improved AMI outcomes compared with all the major HMOs in the Chicago metropolitan area The referral pattern of AMIs PCPs compares favorably with historical referral patterns generated by traditional
Data Analysis
AMIs outcomes data are based on claims incurred Data were collected in parallel by the HMO and Independent Health Resources IHR, which functions as AMIs thirdparty administrator TPA The HMO specifically analyzed all inpatient costs, outpatient facility costs, and pharmaceutical usage AMI, via its TPA, analyzed all inpatient and outpatient professional encounters and utilization, as well as outpatient laboratory The HMO reported all utilization back to AMI on a 6-month delay to allow for the reporting of all claims during the experience period This reporting method produced actual claims, removing the potential inaccuracies of claims incurred but not reported
IBNR
Data Reporting
The HMO prepared quarterly reports to AMI on such managed care benchmarks as: Hospital admissions per 1000 members Total hospital days per 1000 members Outpatient surgical cases and procedures per 1000 members Average length of stay Pharmaceutical utilization and cost per member/per month
Journal of Manipulative and Physiological Therapeutics Volume 27, Number 5
Sarnat and Winterstein Integrated Medical IPA
343
Table 6 Analysis of referral patterns on AMI HMO population,
calendar year 2000
1 Average number of members during 2000 4987 member months/12 2 Total number of referrals 3 Total number of unique patients requiring a referral 4 Percentage of population requiring referral to allopathic specialist 167/416 5 Percentage of population managed by chiropractic primary care physicians PCPs without allopathic referral 100 4 416 330 167 40 60
Outcomes: Cost
AMI also received an annual age/sex adjusted risk pool analysis of its members by the HMOs actuarial
department Derived from this risk pool analysis was a hypothetical budget of predicted expenditures excluding pharmaceuticals for AMIs actual membership defined as the utilization management fund UM fund This budget was calculated in target usage units that have an assigned dollar equivalency IPA actual performance was then calculated against IPA-predicted performance AMIs utilization management fund cost savings below predicted budget were 667, 881, 571, and 693 for the calendar years 1999, 2000, 2001, and 2002, respectively It is believed that the improvement in cost effectiveness between year 1 1999 and year 2 2000 occurred primarily due to an innovative mental health initiative In calendar year 1999 AMIs first year, 33 of the hospital days were categorized as mental health Beginning in calendar year 2000 AMIs second year, a quality initiative targeting stress management techniques was introduced to impact the high percentage of mental health admissions In the subsequent 3 years
following this initiative, mental health admissions have accounted for less than 2 of all hospital days utilized This protocol relied heavily on mind/body techniques such as cranial sacral therapy and energy balancing, as well as more traditional cognitive therapy
AMI, Alternative Medicine, Inc; HMO, health maintenance organization
allopathic IPAs utilizing internists, pediatricians, or OB/ GYNs as PCPs As shown in Table 6, the strategy of comanagement resulted in only 40 of the AMI membership requiring an allopathic specialist referral in the calendar year 2000 In other words, during the year 2000, 60 of \the patients were managed solely by their primary care chiropractic physicians Referral data analysis annualized for the year 2001 shows AMI primary care chiropractic physicians generated 1 referral per 33 patient encounters 1:33 ratio This is in contrast to data generated from comparison group II illustrating that conventional medicine PCPs generate 1 referral per 3 patient
encounters 1:3 ratio This referral pattern was consistent with our prediction that an increase in CAM-oriented PCP encounters initially would result in less utilization of conventional medicine downstream In addition to the clinical outcomes referenced in Table 6, measures of Quality Care were benchmarked by randomized patient satisfaction surveys and an annual audit of all UM/UR Committee documents by the HMO nursing administrators Annually, the HMO independently surveyed by stratified random selection over 45,000 patients Response rates were between 25 and 30 annually The HMO required a minimum score for patient satisfaction to be between 80 and 90, depending on the calendar year AMI member satisfaction scores for the first 4 years were 100, 89, 91, and 90, respectively Analysis of HMO member satisfaction surveys demonstrates the AMI members consistently rated their experience with AMI above the HMO network normative average Annual audit scores measuring IPA compliance with
Utilization Management Adherence/Utilization Review Activity written policy and procedures conducted by HMO onsite nurse auditors also were above the HMO network normative values AMIs annual audit scores for medical administration and medical management were between 97 and 100 in each category The HMO minimum required score for IPA performance is 90
DISCUSSION
Certainly, we now appreciate the importance of lifestyle and environmental factors in the optimization of health and subsequent prevention of disease Reliance on the conventional medical model, in which pharmaceuticals and surgical interventions represent first-line treatment, may not provide the best therapeutic index to our patients The AMI model seems to demonstrate the potential superiority of an integrated health system in which chiropractic and CAM therapies play a significant primary care role Traditional PCPs, be they MDs or DOs, have little formal training in the various evidence-based techniques within the CAM arena
Doctors of Chiropractic, however, receive extensive formal training in the arts of spinal manipulation, herbal medicine, and nutrition, as well as conventional modern physical diagnosis Most of the AMI PCPs electively received additional postgraduate training in homeopathy, TCM, and other CAM modalities Students of chiropractic learn to auscultate heart and lungs, draw blood, and read electrocardiograms EKGs, as well as perform pelvic and rectal exams However, the educational focus and scope of practice laws vary among chiropractic colleges and states, respectively
344
Sarnat and Winterstein Integrated Medical IPA
Journal of Manipulative and Physiological Therapeutics June 2004
It is incumbent on the primary care physician, of whatever licensure, to look at all evidence-based risk factors and seek to coordinate their reduction Most of the time this will involve the re-education of patients regarding lifestyle choices such as diet, exercise, nutrition, supplementation, correction
of posture, and stress management issues Lifestyle re-education emphasizing prevention and wellness may be best addressed by PCPs with an unconventional medical orientation, as opposed to conventional medical physicians who have been educated and focus primarily on disease management The AMI experience seems to indicate that a nonpharmaceutical/ nonsurgical orientation can reduce overall health care costs significantly and yet deliver high-quality care These results have been achieved not by decreasing or denying access to care but, rather, by increasing the frequency of PCP prevention-oriented encounters The chiropractic profession is the largest stakeholder in the ongoing evolution of integrating CAM therapies into mainstream conventional medicine Doctors of Chiropractic are licensed in all states, compared with Doctors of Naturopathy licensed in 11 states and Doctors of Oriental Medicine licensed in only 5 states Acupuncturists and massage therapists are licensed in 40 and 30
states, respectively Chiropractic is the most commonly utilized CAM therapy, as published in many previous surveys Yet, paradoxically, core coverage by insurance benefit design rarely includes unrestricted access to chiropractic Instead, a myriad of excuses both by the private insurance industry and by the federal government currently reduce ones personal freedom by restricting access to choose unconventional medicine, even when practiced by licensed physicians in good standing Various authors believe the restrictions on covered benefits for CAM therapies and unconventional physicians are indefensible, given the growing evidence base on these therapies51 Discount affinity programs promoted as a value added service are currently the most common insurance format by which CAM therapies are available In reality, these programs are not covered insurance benefits at all They do not place the mainstream insurance underwriter at financial risk Rather, they provide the insured with a discount
off market fee-for-service rates for severely restricted pseudo benefits52 The American Chiropractic Association ACA, the largest professional association representing the largest stakeholder to the delivery of CAM therapies, has formally rejected discount affinity programs as an insurance sham53 While the availability of discount affinity programs gives the public the illusion that CAM therapies are a covered service on par with conventional medicine, that is not the case The AMI Wellness Model, by contrast, has been formally recognized by both the ACA and the American Academy of Chiropractic Physicians as a future template of an integrated medical model, which is front-end loaded
to address prevention and wellness An increase in initial PCP services is required by the patient to re-educate and emphasize the modification of inappropriate lifestyle choices, thereby re-empowering the patient toward improved self-determination The good news is that within a 3- to 4-month time period,
much of the behavior responsible for the etiology of new or chronic disease has been modified The initial investment of time, energy, and financial resources for CAM therapies has been successful, apparently much more successful than a quick pharmaceutical prescription and a hasty visit with a conventional PCP typical of the way managed care is practiced today Recently published literature also suggests patient preference and increased satisfaction with integrative therapies for chronic disease states In the articles by Eisenberg et al54-56 comparing patients subjective perceptions as to the relative value of conventional care versus CAM therapies, in only 3 of 10 therapies was conventional medicine perceived as superior to CAM therapies The 3 disease states scoring higher for conventional medicine were high blood pressure, lung conditions, and digestive conditions By contrast, back conditions, allergies, fatigue, arthritis, headaches, neck conditions, and strains and sprains were
perceived better treated by CAM therapies54-56 AMIs higher percentage of members with ICD-9 codes for orthopedics, mental health, chronic sinus, allergy, gastrointestinal problems, and headaches versus the comparison group enrollment is consistent with this pattern
Limitations
This articles methodology is a nonrandomized longitudinal population study comparing and contrasting both clinical and cost outcomes among similar populations enrolled in the same insurance product for the same time frame and geography The strengths of this articles methodology are numerous: 1 study length of approximately 4 years; 2 cost and clinical data reported at arms length by the actuarial department of the HMO to the IPA; 3 availability of matched comparison groups for blinded analysis of membership population for ICD-9 comparisons; 4 availability of randomized patient surveys generated by the HMO to analyze both membership satisfaction with ongoing treatment and preexisting risk factors, such as
lifestyle behaviors tobacco usage; 5 availability of corroborating data, such as pharmaceutical usage and specialist consultations, to cross-check the accuracy of membership ICD-9 population profiles; and 6 patient-oriented medical management, whereby a variety of CAM therapies were individualized for each patient in the real life setting of a metropolitan-wide IPA doing business as a clinic without walls Of course, this articles methodology also suffers from inherent weaknesses: 1 the relatively limited enrollment
Journal of Manipulative and Physiological Therapeutics Volume 27, Number 5
Sarnat and Winterstein Integrated Medical IPA
345
of AMIs membership population versus the matched comparison groups; 2 the inability to determine the exact effect of membership transfer in and transfer out on the cost and clinical outcomes; 3 lack of uniformity in disease-specific treatment protocols utilized among all AMIs physicians; 4 no randomization of comparative IPA memberships; and 5
inability to perform standardized statistical probability analysis due to industry nonavailability of required actuarial data So, at the end of the day, where does this leave us? Have we derived valid and credible knowledge that is useful? At the very least, this article, for the first time, has demonstrated that a select group of chiropractic physicians successfully functioned in both a safe and effective manner as PCPs in a classical gatekeeper HMO model Second, it has demonstrated that these same chiropractic physicians were capable of initiating and coordinating care for patients with a broad spectrum of disease states, representing a wider variety of diagnostic presentations than is commonly seen in most chiropractic offices Third, the magnitude of improvement in both clinical and cost outcomes compared with normative values is so large that it is difficult to dismiss as purely coincidental to population bias and nothing more While admittedly the data are not definitive because of
all of the methodological concerns enumerated, this article seems to demonstrate, for the first time, the potential superiority of integrating a nonpharmaceutical/nonsurgical-oriented gatekeeper or entry point with our already existing conventional health care system Why should this change in PCP orientation make seemingly such a profound impact on outcomes?
benefits and that employee or insurance turnover is too high to wait for an extended turnaround time The AMI experience suggests that cost savings may occur in the first calendar year of operations The magnitude of improvement in both clinical outcomes and cost savings documented herein may not remain constant when the AMI model is utilized on larger and more diverse populations However, even a small percentage of the AMI outcomes would still have significant implications, given a 13 trillion national health care budget At such a high price, AMIs initial results should warrant additional funding for a larger and better controlled
replication of these findings
ACKNOWLEDGMENTS
We wish to acknowledge the following people: Dr Dana Lawrence for editing assistance, Jay M Jaffe, for actuarial consulting, Marcia Marek, Angela Miller, Rose H Homma, and Nancy J Rothermel for secretarial support, and all of our AMI HMO Primary Care Chiropractic physicians for their spirit and dedication to this project
REFERENCES
1 Jencks S, Schieber G Containing US health care costs: what bullet to bite? Health Care Financ Rev Annu Suppl 1991;1-12 2 Congressional Budget Office Managed competition and its potential role to reduce health spending Washington DC: US Government Printing Office; 1993 3 Teisberg E, Porter M, Brown G Making competition in health care work Harv Bus Rev 1994; July-August:131-141 4 Davis K, Anderson G, Rowland D, Steinberg E Health care cost containment Baltimore: Johns Hopkins University Press; 1990 5 Burner S, Waldo D, McKusik D National health expenditures projections through 2030 Health Care Financ Rev
1992;14: 1-29 6 Luke RT Health care in the United States: current and future challenges Manag Care 2001;10Suppl:2-6 7 Cowan CA, Lazenby HC, Martin AB, McDonnell AB, Sensenig AL, Smith CE, et al National health expenditures: 1999 Health Care Financ Rev 2001;22:77-110 8 Hadley J, Zuckerman S, Iezzoni LI Financial pressure and competition Changes in hospital efficiency and cost-shifting behavior Med Care 1996;34:205-19 9 Hoffman C, Rice D, Sung H Persons with chronic conditions: their prevalence and costs JAMA 1996;276: 1473-79 10 South-Paul JE, Grumbach C How does a changing country change family practice? Fam Med 2001;33:278-285 11 McGinnis J, Foege W Actual cause of death in the United States JAMA 1993;270:2207-12 12 US Department of Health and Human Services Healthy people 2000: national health promotion and disease prevention objectives Washington DC: Government Printing Office; 1991 DHHS Publication No PHS 91-50212
CONCLUSION
AMIs integrative medicine IPA represents a new model in
the delivery of managed care This unique model has demonstrated promising clinical and cost outcomes by the integration of complementary alternative medicine with conventional medicine in a defined program encompassing physician selection, medical management, and scientific accountability AMI believes this model to be replicable on a much larger scale and is currently implementing different programs, such as preferred provider organization PPO, point-of-service POS, and Workers Compensation to new geographies AMIs HMO outcomes reported herein were the results of an initial prototype still in evolution The performance of physicians with other licensures, such as Doctors of Naturopathy and Doctors of Oriental Medicine, as well as MDs and DOs who are nonpharmaceutically oriented needs to be studied in this context as well The traditional argument against coverage for preventionoriented medicine is that it will not reap immediate financial
346
Sarnat and Winterstein Integrated Medical
IPA
Journal of Manipulative and Physiological Therapeutics June 2004
13 US Department of Health, Education and Welfare Task force on preparation of drugs: final report Mod Med p 35 Cited by: Griggs B Green pharmacy: the history and evolution of western medicine Rochester VT: Healing Arts Press; 1981, 1991 p 286 14 Classen DC, Pestonik SL, Evans SE, Burke JP Computerized surveillance of adverse drug events in hospital patients JAMA 1991;266:2847-51 15 Hayward RA Counting deaths due to medical errors JAMA 2002;288:2404-5 16 Gabel RA Counting deaths due to medical errors JAMA 2002;288:2404-5 17 New drug abuse trend: prescription medication Associated Press April 11, 2001 Cited by: Welshimer G Health care in crisis Associated Press September 4, 2001 p 2 18 Sanchez JE A look in the mirror A critical and exploratory study of public perceptions of the chiropractic profession in New Jersey J Manipulative Physiol Ther 1991; 14:165-76 19 Meade TW, Dyer S, Browne W, Townsend J, Frank AO Low
back pain of mechanical origin: randomized comparison of chiropractic and hospital outpatient treatment BMJ 1990; 300:1431-7 20 Meade TW, Dyer S, Browne W, Townsend J, Frank AO Randomized comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow-up BMJ 1995;311:349-51 21 Koes BW, Bouter LM, van Mameren H, Essers AH, Verstegen GM, Hofhuizen DM, et al The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific neck and back complaints: a randomized clinical trial Spine 1992;17:28-35 22 Triano J, McGregor M, Hondras MA, Brennan PC Manipulative therapy versus education programs in chronic low back pain Spine 1995;20:948-55 23 Giles LGF, Muller R Chronic spinal pain syndromes: a clinical pilot trial comparing acupuncture, a non-steroidal antiinflammatory drug, and spinal manipulation J Manipulative Physiol Ther 1999;22:376-81 24 Bronfort G, Goldsmith C, Nelson CF, Boline PD, Anderson AV
Trunk exercise combined with spinal manipulative or NSAID therapy for chronic low back pain: a randomized, observer-blinded clinical trial J Manipulative Physiol Ther 1996;19:570-82 25 Kirklady-Willis WH, Cassidy JD Spinal manipulation in the treatment of low-back pain Can Fam Physician 1985;31: 535-40 26 Pope MH, Phillips RB, Haugh LD, Hsieh CY, MacDonald L, Haldeman S A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain Spine 1994;19:2571-7 27 Blomberg S, Varsudd K, Mildenberger F A controlled multicenter trial of manual therapy in low back pain: initial status, sick leave and pain score during follow-up J Orthop Med 1994;16:2-8 28 Berquist-Ullman M, Larsson U Acute low back pain in industry: a controlled prospective study with special reference to therapy and confounding factors Acta Orthop Scand 1977; 170Suppl:1-117 29 Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH
Spinal manipulation for low-back pain Ann Intern Med 1992;117:590-8 30 Anderson R, Meeker WC, Wirick BE, Mootz RD, Kirk DH, Adams A A meta-analysis of clinical trials of spi-
31
32
33
34 35
36 37 38 39 40 41
42
43
44 45 46 47 48
49
nal manipulation J Manipulative Physiol Ther 1992;15: 181-94 Branson RA Cost comparison of chiropractic and medical treatment of common neuromusculoskeletal disorders: a review of the literature after 1980 Top Clin Chiropr 1999;6: 57-68 Jarvis KB, Phillips RB, Morris EK Cost per case comparison of back injury claims of chiropractic versus medical management for conditions with identical diagnostic codes J Occup Med 1191;33:847–52 Nyiendo J, Lamm L Disability low back Oregon workers compensation of claims Part I: methodology and clinical categorization of chiropractic and medical cases J Manipulative Physiol Ther 1991;14:177-84 Nyiendo J Disability low back Oregon workers compensation of claims Part II: time loss J Manipulative Physiol Ther
1991;14:231-9 Nyiendo J Disability low back Oregon workers compensation of claims Part III: diagnostic and treatment procedures and associated costs J Manipulative Physiol Ther 1991; 14:287-97 Johnson MR A comparison of chiropractic, medical and osteopathic care for work-related sprains/strains J Manipulative Physiol Ther 1989;12:335-44 Wolk S An analysis of Florida workers compensation claims for back-related injuries J Am Chiropr Assoc 1988; 27:50-9 Dean H, Schmidt R A comparison of the cost of chiropractors versus alternative medical practitioners Richmond VA: Virginia Chiropractic Association, 1992 Stano M, Smith M Chiropractic and medical costs of low back care Med Care 1996;34:191-204 Smith M, Stano M Costs and recurrences of chiropractic and medical episodes of low-back care J Manipulative Physiol Ther 1997;20:5-12 Manga P, Angus D, Papdopoulos C, Swan W The effectiveness and cost-effectiveness of chiropractic management of low-back pain Richmond Hill, Ontario, Canada:
Kenilworth Publishing; 1993 Manga P Enhanced chiropractic coverage under OHIP as a means for reducing health care costs, attaining better health outcomes and achieving equitable access to health services Report to the Ontario Ministry of Health 1998 Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR The outcomes and costs for acute low back pain among patients seen by primary care practitioners and orthopedic surgeons North Carolina Back Pain Project N Engl J Med 1995;333:913-7 Cherkin DC, MacCornack FA Patient evaluations of low back pain care from family physicians and chiropractors West J Med 1989;150:351-5 Bulletin, 2002 2003 Lombard IL: National University of Health Sciences; 2002 Doxey TT, Phillips RB Comparison of entrance requirements for health care professionals J Manipulative Physiol Ther 1997;20:86-91 Meeker W, Haldeman S Chiropractic: a profession at the crossroads of mainstream and alternative medicine Ann Intern Med 2002;136:216-27 Rao JK, Mihaliak K,
Kroenke K, Bradley J, Tierney WM, Weinberger M Use of complementary therapies for arthritis among patients of rheumatologists Ann Intern Med 1999; 131:409-16 Richardson MA, Sanders T, Palmer JL, Greisinger A, Single-
Journal of Manipulative and Physiological Therapeutics Volume 27, Number 5
Sarnat and Winterstein Integrated Medical IPA
347
50 51 52 53 54
S Complementary/alternative medicine use in a comprehensive cancer center and implications for oncology J Clin Oncol 2000;18:2505-14 National data source MMWR Morb Mortal Wkly Rep 2000;50:1101-6 Vandenbroucke JP, de Craen AJM Alternative medicine: a mirror image for scientific reasoning in conventional medicine Ann Intern Med 2001;135:507-13 Smith JC The CAM scam Clin Chiropr 1999;11-3 ACA on CAM J Am Chiropr Assoc 2000;374:28 Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins
DR, Delbianco TL Unconventional medicine in the United States New Engl J Med 1993;328:246-52 55 Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S,
Van Rompay M, et al Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey JAMA 1998;280:1569-75 56 Eisenberg DM, Kessler RC, Van Rompay MI, Kaptchuk TJ, Wilkey SA, Appel S, et al Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey Ann Intern Med 2001;135:244-51
