Integrative Healthcare: Value Ready in 2016?

[This article originally appeared on the Altarum Institute Health Policy Forum blog,  and is used with permission.]

The advances made across the archipelago of integrative health and medicine disciplines in 2015 continue to be significant. If not yet a “movement,” the practices continue their inexorable flow into the established precincts of medicine, wellness, and prevention.

And they are likely to find more adoption in 2016. Here are a few to watch.

Integrative Health in Employer Care and Wellness Plans

During 2015, Mark Bertolini, chief executive officer (CEO) of Aetna, appeared frequently on news programs, accompanied by videos of his employees in yoga sessions or practicing meditation, accounts of their improved health, and his report of reduced cost of care for his employees. His is an impressive and forthright story of traversing a personal experience that led to integrative options (in recovery from a serious accident) to integration of those care and prevention options for his employees.[1]

In the week before Thanksgiving, the American Sustainable Business Council (ASBC) will host a webinar for its member businesses across the country to examine “Reimbursement for Integrative Healthcare.” ASBC wants to see the experience of Aetna and other companies that provide integrative health care to employees become available to all employers.

But that is not likely to happen until insurance reimbursement for treatments like those available to self-insured companies like Aetna become widely available. That is why the ASBC campaign focuses on joining a growing national consensus to fix shortcomings in provisions in the Patient Protection and Affordable Care Act (ACA): Section 2706, “Non-discrimination in healthcare.”[2]

Section 2706 was written to ensure that health insurers end generations of discrimination against licensed healthcare professionals, notably those in the integrative health disciplines: acupuncture and oriental medicine, chiropractic, naturopathic medicine, licensed massage therapy, and certified professional midwives. The law went into effect January 1, 2014, but has generated little compliance since.

ASBC will produce the webinar with the Integrative Health Policy Consortium (IHPC),[3] the primary public policy organization for the integrative professions. In October 2014, IHPC created CoverMyCare.org, a resource and clearinghouse for state-based advocacy around Section 2706 and for the legislative initiatives that are emerging in the wake of noncompliance. The webinar will show where state-based businesses can help expand coverage. (Disclaimer: I manage CoverMyCare.)

Back to the States and Nondiscrimination in Health Care

In September, ASBC and IHPC co-signed letters of congratulations to the governors of Oregon (Kate Smith) and Rhode Island (Angi Raimondo) on the occasions of their signing bills that copy directly from the language and intent of ACA Section 2706.

Since I reported on this state-based phenomenon in July,[4] advocates in Minnesota, Hawaii, California, and New Mexico have been preparing to introduce similar bills in their legislatures in 2016; others may follow. In June, the Oregon Association of Naturopathic Physicians doubled down on Section 2706 by filing suit in federal court against the Health Net Health Plan of Oregon and its contracted benefits provider American Specialty Health on behalf of a group of patients, alleging “unlawful and discriminatory practices.”[5]

Bringing the issue of health care provider nondiscrimination to the states is an interesting unintended consequence, because each state’s regulator licenses both its professional health care providers and the health insurers who operate in their state. The participation of employers through ASBC now brings the actual premium payers into very local conversations. Whether these cohorts of providers, patients, and payers will make a coherent case for compliance with Section 2706 or generate their own homegrown legislative variants will be worth watching during legislative sessions of 2016.[6]

Integrative Health in Value-Based Payment Structures

A benefit of integrative interventions that has long been clear inside its professions but hardly at all outside of them is the cost advantage that can come from treatment for various conditions. Perhaps the most widely acknowledged now is the use of acupuncture to complement or even replace painkillers and to help addicted patients get off overprescribed opioids. Pain is one of several chronic conditions that integrative interventions have shown to provide equal or better outcomes, often at lesser cost because of the absence of side effects and shortened treatment periods. (IHPC released a summary of extensive research in such cost comparisons in March of 2015.[7])

Increased awareness of these cost-reducing outcomes is likely to become exceedingly important for the integrative provider community as the U.S. Department of Health and Human Services (HHS) advances its ambitious plan to move Medicare payments to value and quality.

The Better, Smarter, Healthier program announced in January 2015 by HHS Secretary Sylvia M. Burwell is “the first time in the history of Medicare that HHS has set explicit goals for alternative payment models and value-based payments.”[8] The program is based on tying traditional fee-for-service Medicare payments to quality or value through alternative models such as Accountable Care Organizations (ACOs) or bundled payment arrangements. The percentage of payments to be directed to these models:

• 30% by the end of 2016
• 50% by the end of 2018

Although the integrative professions have very strong advantages here, the disciplines are invariably not included in Medicare coverage. Although Section 2706 of the ACA is designed to open patient access to insurance reimbursement for these disciplines, there is oddly no corresponding opening of access in Medicare—“oddly” because the nondiscrimination language of Section 2706 appears to have been lifted directly from previously established rules for Medicare+Choice and Medicare Advantage.[9]

Value Through Integrative Collaboration

The HHS transition to value-based payment structures mirrors collaborations in the private clinical marketplace that have been accelerated by the ACA’s emphasis on the patient-centered medical home model and ACOs. Clinical teams combining medical doctors and doctors of osteopathy with naturopathic physicians, acupuncturists, massage therapists, nutritionists, and others predate the ACA by at least a decade.

Few of those teams, however, have been formed since the ACA to take advantage of the value-centric objectives of reducing the costs of care. A significant early example is Casey Health Institute (CHI), a nonprofit integrative primary care provider in Gaithersburg, Maryland, formed in 2012. CHI has moved steadily through the PCMH certification process in Maryland, and it recently signed up to join five other primary care organizations (none integrative) to form an ACO.

CHI CEO David Fogel, MD, sees transformational potential in these models once they work through the thicket of requirements. “The power in integrative medicine is team-based collaboration,” he said. “I think we will blow values-based metrics out of the water with our outcomes using a team-based staff model of care.”[10]

A potent example of this potential in both private market and very likely for Medicare cost containment was described earlier this year in a HuffPo.com piece by the well-known physician David Katz, MD, founder of the Yale Prevention Research Center and now president of the American College of Lifestyle Medicine. Dr. Katz’s seminal description of his successful clinical work with naturopathic physician colleagues is of great interest in itself. In his account, he notes:

“I found that my colleagues in naturopathy often had new things to recommend when I had run out (of solutions). And more importantly, I found that by working together a higher percentage of my patients got better. In particular, we were better together at treating the hard stuff: chronic pain, chronic fatigue, and various esoteric syndromes.”[11]

When I asked Dr. Katz recently whether lifestyle interventions that include integrative therapies were reimbursed by insurance, he said, “Sometimes, yes, but mostly no. It is an important question.”

That question will be addressed in 2016 by advocates in the states who will continue to demand and/or create compliance with Section 2706. Perhaps HHS will even exhume its own provider nondiscrimination language and embed it in its aggressive timetable to reduce the costs of treating Medicare patients, many of whom suffer the conditions that Dr. Katz and others have successfully treated in partnership with integrative colleagues.

Taylor manages the website http://www.covermycare.org, which tracks compliance with Section 2706 in the states as part of its consumer information and engagement mission.