McGrady's response - 08:20am Apr 16, 2002
I am not familiar with a specific example of acupuncture in a skilled setting. I would think there would be two issues, credentialing and reimbursement. The credentialing part may depend on your State laws, however I would think you could use a process similar to other allied health categories. The challenge comes for establishing peer review, but you may be able to find someone in your area able and willing to do this, but you should expect to pay them. The American Academy of Medical Acupuncture (www.medicalacupuncture.org) is an organization of physicians who practice acupuncture and this may be a resource to bridge the gap.

Getting paid in the skilled setting is another issue and may be more problematic, particularly if most of your patients are on Medicare. You may want to have a conversation with your area HCFA representative if you haven't yet done so.

Good Luck, Elizabeth

McGrady'sresponse - 09:15am Apr 16, 2002
It was the academic medical centers that first started integrating complementary modalities with traditional medicine, so your setting should be OK. The Duke Center for Integrative Medicine is a recent example and they have information on their web page. The University of Maryland is another example. They have received funding from NCCAM for research. The NCCAM web page will give you some idea of the possibility of funding and the type of research that is being funded. That is one route to go in obtaining money for your program.

In terms of what are the profitable CAM services you should read an article by Mark Hofgard and Melinda Zipin in the May/June 1999 MGM Journal entitiled, Complementary and alternative medicine - a business opportunity. They did a nice job of listing some of the Eisenberg and Landmark utilization data as well as giving a range of salaries and fees for certain CAM providers, as well as discussing other financial aspects of CAM services and programs.

In the financial models I have structured, chiropractics, acupuncture, and massage therapy have the largest demand and potential profitability. However, it really depends on how you set it up. Hospitals stand to make the same mistake as they did with the purchase of physician practices. The economics, and dynamics of CAM practitioners can be very similar to owning or managing a primary care practice. If you pay too much for the practice, the practitioner and the support staff, lay too much hospital overhead stuff on it, it will not be profitable.

The herb and supplement area has the highest profit margin but this is a retail business that must be run very differently than most medical center types of services. If you have home medical equipment or other retail outlets maybe this could work, but it will probably make your pharmacy people nuts.

In terms of attracting paying clientele, I think the keys are certainly the aesthetics, but also the setting. It has to be convenient and have easy access and parking. I think that in your setting start off by selling it to your employees, maybe at a discounted fee, and perhaps other businesses located in your proximity.

The bottom line is that the margins on CAM services are very small. A realistic goal is to get to breakeven in 18 months to 3 years for a well organized and managed program. Start small, and form relationships with quality providers. Consider a "without walls' type program that is loosely structured but establishes referral patterns and relationships and allows for joint marketing. Contract rather than employ and put the provider at risk.

Another area is the stress management energy work, mind-body types of modalities. I think these are wonderful ajuncts to the more clinical types of services. However, there are not CPT codes and insurance coverage for many of these types of services, but they can still be profitable if structured correctly. The Mind/Body Institute of Jupiter Medical Center in Jupiter Florida is an example of a community hospital that is doing some interesting programs, much of it fee for service. They offer healing movement, healing touch, and psychological services in addition to acupuncture/traditional chinese medicine, nutrition, magnetic field therapy, and homeopathy.

Good luck, Elizabeth

McGrady's response - 04:21pm Apr 9, 2002
Mark,
In my experience I have seen different rural organizations implement CAM services. I think many areas of the country including certain urban areas still see resistance to CAM, so you are not alone. What I think is the biggest single variable in the successful integration of CAM services is to have a strong clinical champion. It can be a physician or a CAM provider, but someone who has a vision and the tenacity to see it through.

In Kingsport, Tennessee, which I consider rural, a pair of physicians affiliated with the East Tennessee State University family practice program are doing some interesting things with botanicals. In a way this is an extension of the folk medicine practiced in the area historically. One of these physicians Wend Kohatsu, MD trained with Andrew veil, MD and is integrating mindfulness into her treatment regimens. The hospital there has implemented a Plane tree unit.

Another rural example is Yavapai Regional Medical Center in Northern Arizona. They developed and implemented a total healing environment initiative. Last I heard they wanted to introduce some healing touch services but they were finding resistance for that. There is an article in the Journal of Healthcare Management 44(6):495-512 on this program.

In general I think you need to to match the CAM expertise that currently exists with community demand. That often means starting small and proceeding in a way that limits risk and exposure. Massage therapy can actually be a difficult program to initiate in the hospital setting because people don't expect to see it there and the growth is often slow going, though I agree it is a natural fit. But you need to make sure that the environment where you provide the service is conducive to relaxation and the aesthetics people expect for the outpatient side. In general, it can be the most easily accepted CAM modality by physicians because nurses used to do it all the time. However, if you plan to do massage, on inpatients particularly, you need to develop policies and procedures to ensure it's done right and on the right people. Monongalia General Hospital in Morgantown (which is not rural but the surrounding area is), West Virginia is in the process of doing that right now. They are using a nurse who is also a massage therapist to develop their program. Some hospitals limit massage to outpatient services only. A way to begin massage is to see if there is someone already employed in your organization, a nurse or PT assistant for example, who is a massage therapist and wants to transition to that practice.

Oftentimes the successful integration of CAM services is about changing how you do things as much as what you do. The CAM center approach has been met with limited success much like the acquisition by hospitals of primary care practices. While the total dollars spent on CAM services is very large, a lot of that is spent on nutraceuticals which have the biggest mark-up because it's retail.

In the Winter 2000 edition of Frontiers, Carol Freshley included a good checklist for the questions you should ask yourself in developing a CAM program. That may provide some guidance and insight.

What I do believe to be true is that CAM is here to stay, it is not a fad. I believe many modalities are very effective, particularly acupuncture, and that the reason that healthcare organizations need to integrate CAM modalities is that they are good medicine, and in some instances the best medicine. But I also believe that it is prudent to move slow, build upon strengths, and look for ways to make connections and form relationships with CAM providers as independent practitioners as opposed to owning them.

Hope this helps, Elizabeth

McGrady'sresponse - 08:29am Apr 22, 2002
Dick,
You may want to start with a survey of your physicians regarding CAM issues. In the survey you could leave a space where they could indicate interest and then follow up with those indicvidual physicians one on one. I agree having a champion is very helpful and maybe imperative. In my experience I have found that there are physicians who are proponents either through personal experience or through family or friends or maybe even a patient, but they are very quiet about it because they are concerned about ridicule from their peers. As we know, physicians rely on other physicians for referrals.

Another approach that I have seen used is to sponsor an educational presentation on CAM for your physicians. You may want to include your Board members and key staff as well. You could invite a physician to speak on the integration of CAM. Most medical schools are offering some form of CAM in their curriculum, so that may be a source. There are other "name" physicians but of course that will cost more. In any event, see who comes to the presentation and start contacts from there.

A third approach is to conduct personal interview with those you might suspect as being open.

I agree that starting small is a good idea. Product line integration is a good start. You may want to think first about what strong CAM practitioners you have available and work from their strengths. Cancer is always a good place to start as well as women's services. You may also want to survey your employees. Many times you have people working for you that are trained in a modality who would like to transition from being a nurse or physican therapist.

I think integration of CAM needs strong leadership, but it doesn't have to be a physician. I know of a hospital that is being lead by a nurse who is a massage therapist for example.

You referenced a large Native American population. That would be another interesting place to start to see if there are practices they would like to see integrated. There is a textbook out published by Mosby called Complementary and Alternative Medicine - A Research-Based Approach, Freeman and Lawlis. This book is more science-oriented it so may help in working with physicians.

Good luck, Elizabeth

McGrady's response - 08:55am Apr 22, 2002
Credentialing is a challenge. Your state laws are obviously making it harder, but most practitioners have some form of national certification that may help. I think the first rule about credentialing is to to follow whatever approach you use for other types of pratitioners. For example, it may be that you have an allied health category that you use for physical therapist that may fit.

A couple of resources, Michael Cohen is an attorney that is nationally known for CAM issues. He has a book entitled, Complementary and Alternative Medicine, Legal Boundries and Regulatory Perspectives (The Johns Hopkins University Press - 1998). Also, The American Academy of Medical Acupuncture(http://www.medicalacupuncture.org/) has some information about credentialing on their web page. And the Frontiers article referenced on the links to this (Winter 2000) has a little.

The challenge I hear most often is establishing peer review. This is a bigger problem if you are in a more remote area and there is only one acupuncturist in you area. I have had medical affairs staff tell me that what they are facing is similar to podiatry or midwife credentialing. It may be that you will not be able to credential all types of practitioners, but if you are employing some of them you may not need to. You may want to see if any local managed care or insurance companies are credentialing pratitioners, and see what they are doing.

Elizabeth

McGrady's response - 09:29am Apr 29, 2002
I would first say congratulations for attracting a forward thinking physician to your area. Your concern is probably the most common issue I see for community hospitals integrating comlementary services. I have seen community hospital boards concerned about offering yoga because it meant practicing eastern religion to them. The hospital simply changed the name to progressive relaxation exercises and the problem was solved.

I did some work with a private not-for-profit community hospital that had a private physician on staff who was providing several complementary services in her office, some of them homeopathic. One of them was chelation therapy with EDTA. This caused great concern in some of the medical staff members. I sent them an announcement from NIH's NCCAM of an RFP for a $6 million 5-year grant they were letting to perform a blind study on EDTA chelation for heart patients. This physician did a radio show on this topic and there was a lot of attention focused on this for a short while then it died down. The point being that one of the concerns by physicians is that they are not familiar with many of these modalities and have not seen outcome studies documenting efficacy. I cannot attest to EDTA one way or the other. But beyond the science we are often talking about entirely different philosophies, ways of viewing life, health and disease and I think this is generally the bigger issue.

In the famous hybrid corn study of middle America the integration of new ideas was documented. Farmers adopted the use of a new corn in a bell-shaped curve. There were the innovators, the early adopters, the mainsteam, the late adopters and those that refused to change despite evidence of the efficacy of the new corn. I think the integration of CAM services will follow this pattern and there will be some people you will never convince.

But you are still faced with helping your key stakeholders become comfortable with innovation. If you have a medical school near you perhaps there is a faculty member with credibility that can present to your board and medical staff about CAM services.

There are community hospitals that are successfully initiating CAM services. Jupiter Medical Center in Jupiter, Florida is one example where they are doing it particularly well. They have a center that is built around an Internal Medicine physician. It is called The Mind/Body Institute and has been in operation since 1998. The offer massage, acupuncture, psychotherapy, hypnosis, guided imagery, meditation, aromatherapy, homeopathy, traditional chinese medicine, craniosacral therapy, lymphatic drainage, nutrition, music/art therapy, tai chi, and qi-gong. I could name many others in Cincinnati, Savanah, Morgantown, San Antonio, and New Orleans.

A couple of books that may be helpful are Michael Cohen's Complementary and Alternative Medicine - Legal Boundries and Regulatory Perspectives (The Johns Hopkins University Press) and Complementary and Alternative Medicine - A Research-Based Approach, Freeman and Lawlis (Mosby).

Though I realize that you are dealing in the community hospital setting, it can help if you share with the board and physicians what Harvard and Stanford and Duke and the University of Maryland and the National Institutes of Health, National Center for Complementary and Alternative Medicine are doing as these are prestigious organizations with credibility. Also, if you are a member of a VHA or Premier type organization, check with them because I know they have been looking at the issue.

I think the bottom line is whether the physician is practicing modalities that have no studies and are potentially harmful, that is one issue. But if they are incorporating any of the modalities that were listed at the Jupiter center, those are becoming almost mainstream. You may not be able to convince everyone through education. You may want to perform a market study to see current attitudes and use in your community to help support your effort by demonstrating consumer demand.

Best Wishes, Elizabeth McGrady