When it comes to motivation, money may be the queen among carrots and pain the king among sticks.
Both are increasingly on the side of a more rapid uptake of integrative medicine into mainstream delivery, according to leaders of health systems and military medicine. Representatives of each spoke Nov. 10, 2011 at "Integrative Medicine in Action," a seminar sponsored by the Bravewell Collaborative of philanthropists in integrative medicine that preceded the Bravewell Physician Leadership Award.
Moderator Jonathan LaPook, M.D., the CBS medical correspondent, set the tone at the educational session. He made it clear that this year's program at the New York Palace Hotel would not merely feature opinions on integrative medicine's purportedly transformational philosophy, vision and mission. LaPook, who also moderated a previous iteration of the biennial event, scanned the packed parlor room of individuals who'd paid $250 a person to attend. He declared everyone present a member of the choir. No more preaching, he said. This year the speakers would deliver nuts-and-bolts on the state of integrating healing-oriented, whole person, integrative care within large health care systems and into military medicine.
The field of integrative medicine has moved, as LaPook later put it, "from generalities to the specifics" of implementation. He nodded toward a table where Lt. Colonel Windy Hendrick sat. The F16 fighter pilot was to later present on the positive impact of her integrative health coaching for returning veterans. LaPook joked that if any speaker strayed into philosophizing, he'd pre-arranged with Hendrick to have the back-slider strafed.
LaPook's jest on such a forceful motivational strategy touched the day's pervasive theme. Do powerful incentives exist in the nation's $2.6 trillion payment and delivery system to propel integrative medicine into a leading role in reform?
Close observers know that misaligned incentives are a badgering blues soundtrack for integrative medicine's brief, 15-year history. The field's health-oriented approach runs at counter-purpose to the disease-focus that spawned the $2.6 trillion medical industry.
The challenge was captured recently by Duke University Chancellor Emeritus Ralph Snyderman, M.D., a prior winner of Bravewell's $100,000 prize. He wrote a column in the Journal of the American Medical Association about an integrative outpatient program at Duke University. The program saved $2,200 per employee but was killed by the system. Snyderman explained: "Ironically, because reimbursement compensates in-hospital patient care at a higher level than outpatient services, the health system realized a financial disadvantage, and the program proved economically unsustainable."
In short, getting people healthy is not incentive enough. Speaker Tracy Gaudet, M.D., formerly a coworker with Snyderman at Duke's integrative medicine program and currently the inaugural director of the Veteran's Health Administration's Office of Patient-Centered Care and Cultural Transformation put it this way: "The biggest mistake you can make is to believe that everyone wants to make health better."
But presenter Ken Paulus says this problematic financial climate for integrative medicine is about to be turned on end. Paulus is president and CEO for Minnesota's dominant delivery system, Allina Hospitals & Clinics. He argued that the economic obstacle to expansion of integrative medicine inside health care delivery will change under the Affordable Care Act. Paulus recounted that Allina has "been in this business of treating diseases for 100 years, and we do it very well." The system serves roughly one-third of Minnesota's population. Then Paulus referenced the soaring cost of care in the United States: "Being increasingly broke completely changes the equation."
Paulus took a side journey to underscore his point. He recounted a story he'd heard that intrigued him about an ancient Chinese form of health care payment. Barefoot doctors, he said, were only paid by communities if the people in their charge were kept healthy. Fast forward to the new payment forms in Obama's Accountable Care Organizations and Patient Centered Medical Homes. "For the first time ever," said Paulus, "the payment will change toward keeping people healthy." He repeated, for emphasis: "For the first time in 100 years it will be our job at Allina to keep the village healthy."
This, Paulus concluded, is where Allina "is headed." And this shift is "the point of inflection" for integrative medicine.
"When I first heard of integrative medicine," he told his audience, "I saw you as an expense." He credited philanthropic support via the Penny George Institute for Health and Healing with keeping the integrative flame alive at Allina. "We've had benefactors for integrative medicine. The George's [Family Foundation] and the Ted and Roberta Mann Foundation have bridged us to where we are going." But now Paulus anticipates that when the Affordable Care Act's payment structure "kicks in that supports keeping people healthy, you will be an asset. Integrative medicine will be an asset."
Presenter Colonel Kevin Galloway turned attention to another well-known motivator. Pain, he said, has brought the U.S. military to adopt holistic and integrative approaches. Galloway is chief of staff of the U.S. Army's Pain Management Task Force and action officer for the Comprehensive Pain Management Campaign Plan. "In the past," shared Galloway, "we used to say when you have more pain, give mor-phine."
This changed in a big way under the guidance and personal experience of Lt. General David Fridovich. Said Galloway: "He made holistic okay. He redefined pain as a functional issue. He told the specialties you need to stop fighting among the tribes and focus on what is the best medicine." Galloway added: "We are rebuilding our system with a multidisciplinary approach. We have acupuncturists and massage therapists around our interventionists. We're forcing them to sit together."
For the 1960s-era baby boomers behind the alternative, complementary and now integrative medicine fields, the idea of the U.S. military leading the uptake of soft-belly, integrative practices can seem oxymoronic. Similarly, most conventional medical professionals don't much like thinking that in the U.S. system, making money and focusing on the health of our villages often proves a challenging fit.
To listen to the speakers brought together by the Bravewell philanthropists, the cobbled motivators of pain and new financial incentives may yet launch integrative medicine as the transformational agent the Bravewell's founders have advocated for a decade.