Berwick's Exit from Medicare a Loss of a Brother-in-the-Trenches for Integrative Medicine

The forced exit of Don Berwick, MD as administrator of the Center for Medicare and Medicaid Services was a double whammy for the emerging field of integrative medicine.
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The forced exit of Don Berwick, MD as administrator of the Center for Medicare and Medicaid Services was a double whammy for the emerging field of integrative medicine.

Berwick is a knowledgeable advocate of the core principles of integrative health care. Few policy leaders are on record as such outspoken supporters. Yet the more profound loss for integrative medicine is Berwick's promotion of what he called the "majestic thing" known as Obamacare.

Berwick'a alignment with integrative principles became apparent in a presentation at the National Academy of Sciences in late February 2009. In a keynote at the Institute of Medicine Summit on Integrative Medicine and the Health of the Public, Berwick ticked off his "Basic Principles for Integrative Medicine."

•Place the patient at the center.
•Individualize care.
•Welcome family and loved ones.
•Maximize healing influences within care.
•Maximize healing influences outside of care.
•Rely on sophisticated, disciplined evidence.
•Use all relevant capacities - waste nothing.
•Connect helping influences with each other.

Nothing in Berwick's prescription will jar the multidisciplinary multitude of integrative health advocates. Patient-centered? Much to the dismay of the dominant school of medicine, patients arguably created the complementary and alternative medicine movement. Berwick's list is enshrined in the definition of integrative medicine endorsed by the 51 medical schools in the Consortium of Academic Health Centers for Integrative Medicine.

Yet the deeper impact for integrative medicine's health-creating orientation is Berwick's promotion of payment and delivery methods that mimic incentives in government-directed systems. The very structures that provoke the ire of Republicans who gave Berwick his pink slip support integrative medicine.

A growing cadre of integrative medicine professionals recognizes the acronym jungle of the emerging ACOs (Accountable Care Organizations) and PCMHs (Patient Centered Medical Homes) as a fertile host for mushrooming use of integrative care.

Ira Zunin, MD, MPH, MBA is the founder of the 40 practitioner Manakai O Malama PCMH-integrative hybrid in Honolulu. Zunin explains in an interview that linking electronic medical records with local hospitals immediately facilitated referrals for his acupuncturists, massage therapists and naturopathic doctors.

Zunin says the more significant friend to integrative medicine in the PCMH is the break from fee-for-service. He explains: "You have unassigned dollars that aren't directly connected to a provider or a procedure or a code. Payment plays into the hand of integrative practice. You can use the dollars from an integrative perspective."

Zunin adds: "The PCMH model is supposed to help the whole person, in his or her community. We [in integrative medicine] have always been looking at everything with a bigger tool set, with a focus on health. We're oriented to this model. We're oriented to teams."

Tom Trompeter, CEO of Healthpoint, agrees with Zunin. For 15 years, his growing network of 10 federally-qualified health centers in the Seattle-area has had naturopathic doctors, acupuncturists, massage therapists practicing alongside their medical doctors, nurses, nutritionists and clinical psychologists. In a recent interview, Trompeter told me in an interview how the PCMH is a "break from the paradigm of a physician owning a patient." He says this opens the door to team care and "the team approach opens the door for diversity" of providers and services. "To use a well-worn term," Trompeter adds, "our approach is holistic."

When I spoke recently with David Moen, MD, the executive medical director with Minnesota's Fairview Health Services, he echoed Trompeter: "Many of today's costs are associated with a lack of a holistic, integrated approach." The new outcomes focus of ACOs is ready made for integrative medicine: "The movement is toward more holistic measurements of health and well-being." Moen spoke readily of the "good evidence that some integrative therapies help a patient's ability to cope." He adds: "Integrative medicine supports self-efficacy."

These new structures won't disappear with Berwick's exit. In fact, Moen and others believe that the shift toward ACOs and PCMHs will continue regardless of any negative judgment by the courts on the Obama-Pelosi reform.

Moving huge agendas, whether to advance integrative health philosophy and practice or to restructure the incentives in the system, is not movement of furniture. Manifesting the principles Berwick outlines for integrative medicine require culture change. Anyone engaged in such sometimes Sisyphian work knows that advocacy from the top is not merely critically important. It is necessary. This is as true for leaders of new ACOs and PCMHs as it is for integrative medicine's line-workers.

With Berwick running CMS, the person in the bully-pulpit of the nation's most powerful payment system was integrative medicine's brother-in-the-trenches. Berwick has a chest full of medals for valor in campaigns to transform our reactive, wasteful system to one organized around keeping people healthy.

Berwick will be missed in ways most of us have not yet begun to imagine.

Disclosure: John Weeks earns part of his living directing a consortium of academic organizations associated with complementary and integrative health disciplines.

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