by Avery Yale Kamila
September 2003
Holistic healthcare continues to gain in popularity, but its practitioners contend with barriers. Issues of licensure and a lack of trained professionals plague the industry. Reimbursement headaches? Take two private pay patients and call me in the morning.
Keith Berndtson’s career changed forever seven years ago. During a routine exam, a patient asked this Chicago doc what could be done for his niece’s ear infections. Berndtson said surgery. When the man came to see him the next year, Berndtson asked about the girl. Turns out, she didn’t need the surgery. She eliminated dairy and wheat from her diet and the infections vanished. This simple remedy came courtesy of a holistic physician.
"I vowed at that moment to close my knowledge gap on these issues," Berndtson says. Before this conversation he (like many physicians) was skeptical of the alternative therapies ignored in his conventional medical training.
These treatments can be divided into two categories: lifestyle modifications and therapeutic interventions. Diet and exercise advice, along with mental and spiritual growth techniques, fill the first category. Herbs, homeopathic remedies, manipulation and acupuncture the second.
Popular with Patients
Today Berndtson is the medical director of Integrative Care Centers, with two locations in the Chicago area. Integrative is the hip way to describe medicine that offers both conventional and alternative treatments. A one-stop-shopping concept that appeals to patients.
The popularity of alternative medicine was first quantified in a 1993 article published in the New England Journal of Medicine (with a follow-up study published in 1998). This watershed research showed that more Americans seek care from alternative practitioners than seek care from traditional doctors.
Berndtson capitalized on this trend when he changed from traditional to integrative medicine. He does little advertising and says patients generally have to wait two months to see him.
Women to Women, based in Yarmouth, Maine, caters to patients who appreciate how the mind, the body and the spirit play a role in health. Donna Poulin, practice administrator, says she does no advertising. Their clients, who come from all over the world, sometimes wait four months for an appointment.
"What attracts patients to us is our reputation--we’re here to listen," says Poulin. It also doesn’t hurt to have author and Oprah-favorite Christiane Northrup, M.D., as a co-founder (even if she no longer sees patients).
Much of integrative healthcare’s popularity is driven by traditional medicine’s lackluster results in certain areas. Issues such as fibromyalgia, chronic fatigue syndrome, asthma, menopause, multiple sclerosis and Crohn’s disease are the reason many patients turn away from traditional docs.
"For the most part, our patients have chronic conditions for which conventional medicine is not particularly well-suited," says Anastasia Rowland-Seymour, M.D.
She is completing a fellowship in integrative medicine at the University of Arizona--the only program of its type in the nation. Soon she will head to SUNY Upstate Medical University in Syracuse, New York to work as a clinician educator.
Ken Jacobson, the executive director of the American Holistic Medical Association, says his organization receives more requests for physician referrals than his staff can handle. To help cope with the demand, the AHMA has launched a new website that includes a database of member physicians and practitioners. The association has 1,000 members.
Where’s the Doc?
Whether caregivers brand themselves as alternative, complementary, integrative or holistic, it’s clear patients want this style of care. Yet despite being in such a strong position for growth, the industry is held back by the availability of practitioners.
Berndtson wants to hire another physician, but says it’s difficult to find someone trained in holistic care. "The residency programs are not pumping out a lot of generalists who are eager to get into integrative medicine," he explains.
Even if he could find someone with the interest, he would have to undertake a significant training program to bring them up to speed on alternative treatments. And for someone running two busy medical practices, such training time isn’t an option.
Women to Women’s Poulin knows most medical people--from nurse practitioners to front office staff--are not familiar with this type of care. "I look at an enormous learning curve when I hire someone," she says.
Victoria Maizes, M.D. is the executive director of the University of Arizona’s integrative medicine fellowship. She says the demand for training is out there, but the teaching capacity doesn’t exist.
"We have way, way more applicants than we could ever take," she says. The program accepts four fellows each year and has produced 20 graduates.
The two-year fellowship was created in 1994 by alternative medicine guru Andrew Weil, M.D. He wanted to start a residency program but was advised that it wouldn’t fly without a national certifying board. A residency program would suit Berndtson, who says a University of Arizona fellow would be overqualified for the position he has to offer.
To address the pent up demand for training, the University of Arizona recently launched an associate fellowship in integrative medicine. These fellows use the Internet and a three week residential program to learn how to provide alternative style care. In 2002, the first class of associate fellows numbered 41.
Jonathan Sheline, M.D., a partner at Integrative Physicians in Durham, North Carolina, is also having trouble finding qualified staff. "We’re looking to bring in a nurse practitioner," says Sheline, "because there aren’t a lot of doctors who are trained in alternative medicine."
Sheline brings up another challenge facing the field--licensure. He and his partner, Janet Lehr, M.D., recently purchased the practice and restructured it based on the advice of their attorney. While under the old management, the office offered patients a naturopathic physician, two massage therapists, a counselor and a psychiatrist--in addition to the two family practice doctors.
All those providers are still under one roof, but they no longer belong to the same group. Instead, Integrative Physicians sublets space to the other practitioners who are responsible for their own billing.
Why the change? North Carolina doesn’t license naturopaths, which created a business risk for the physicians--namely, aiding and abetting unlicensed medicine.
"The availability of complementary practitioners has to do with state licensure statutes," explains George DeVries. He is the president and CEO of American Specialty Health, the nation’s largest alternative medical benefits company. "This is a significant issue in the growth of complementary healthcare," he says.
American Specialty Health provides health plans and alternative provider networks direct to employers and through contracts with other health plans. The growing company, in business since 1987, has nine million enrollees located in all 50 states. They offer a nationwide network of roughly 26,000 providers. Only licensed caregivers are included in this network, so American Specialty Health’s provider mix varies from state to state.
Just 11 states license naturopaths, and the laws are as chaotic when it comes to other specialties, such as acupuncture and massage. DeVries reports that chiropractic is the only alternative field where the states are generally consistent.
Show me the money
Berndtson’s life-changing patient happened to be a vice president at Abbott Labs. He was intimately familiar with the big bucks his company was forking over to provide employee medical coverage.
His niece was covered by insurance but had to pay out-of-pocket for her cheaper care. He challenged Berndtson to explain the soundness of a system that forced patients to go out of network to be healed. "The system doesn’t value the wise generalist," Berndtson now says. "But that’s what patients want."
Berndtson and the Abbott Labs executive aren’t the only ones critical of the current system. Jacobson at the AHMA notes that the "system costs more and more to get less and less." All doctors--particularly primary care physicians--are being squeezed by shrinking reimbursements from private insurers and government programs.
Integrative caregivers face an added hurdle because many natural treatments aren’t covered by third party payors. Maizes explains it this way, "The old model doesn’t support this kind of care, so we’re in a funny transition time."
A recent study by Mercer Human Resource Consulting shows that while 64 percent of employers with HMO plans are covered for chiropractic care, only 27 percent have acupuncture coverage and 22 percent have massage therapy coverage.
Many assume that alternative practitioners work only for cash. This stereotype has a grain of truth. Some holistic healers do operate on a strict fee-for-service basis. Not by choice, typically, but because their services aren’t covered. When it comes to private insurance, most alternative practitioners are happy to take it, if it's available.
Jacobson says AHMA members employ a number of billing practices ranging from purely self-pay to third party reimbursement. All the practitioners contacted for this article say they accept insurance, with the University of Arizona being the one exception. Their clinic accepts cash and Medicare.
Integrative Physicians in North Carolina recently put a temporary freeze on Medicaid and Medicare payments because the reimbursement rate has dropped so low. Berndtson in Chicago has never accepted Medicaid but does take Medicare.
"We’ve played with the idea of becoming self-pay," says Women to Women’s Poulin. "But I don’t think that serves the needs of our patients." She says that "it almost costs more to fill out the paperwork" than they gain in government payments.
Holistic caregivers have one main beef with the third-party payment system--the low reimbursement rate for primary care. Traditional family practice doctors keep afloat by seeing the maximum number of patients each day.
To integrative physicians, such an approach contradicts the foundation of alternative care--listening to and understanding the whole person. A process that typically takes longer than 10 minutes.
Berndston is able to spend more time with his integrative consultations because one-third of his practice is devoted to physical therapy. Which he says has a better reimbursement rate than his other treatments.
It’s clear integrative medicine isn’t a get rich quick scheme. Or even a field likely to provide practitioners with modest wealth. Sheline says that he and his partner will probably each make $60,000 this year, "if that."
Trained as an internal medicine physician, Rowland-Seymour says her salary at SUNY Upstate will be in line with the average pay for internists. "I’m not expecting to make gobs and gobs of money," she says.
She reports there are plenty of jobs available in private practice for someone with her qualifications--"because patients are willing to pay out of pocket"--but says the pickings are slimmer at teaching hospitals.
Still, holistic doctors remain optimistic about the future of their field. The University of Arizona fellowship gives preference to applicants who want to join academic centers and change them from the inside out.
The integrative medicine fellowship began this process by making their own training environment radically different than the status quo. The fellows work a 9 to 5 schedule (for the most part) and are given time during the day for reflection. They are encouraged to eat well, exercise often and practice stress reduction.
"We believe physicians should be role models," Maizes says.
Citing the increasing number of medical schools and residency programs teaching future physicians about nutrition, exercise, alternative treatments and "the art of medicine," Maizes says "that over time, integrative medicine will be part of all residencies."
Rowland-Seymour feels that holistic healing could reduce healthcare costs. She plans to study this when she gets to Syracuse. She also thinks it’s a handy tool for doctors working with people on limited incomes. During her residency at Harlem Hospital in New York City, she counseled her patients about diet and exercise. Both are cheap (but powerful) alternatives to prescription drugs.
"Integrative medicine doesn’t have to be a boutique medicine for the rich," she says. "Hopefully, in the future, it won’t be a sub-field, it will be the cannon."
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