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6 Economics and Policy You can always count on Americans to do the right thing once they have exhausted every other possibility. —Winston Churchill Senator Tom Harkin delivered the keynote address for the session on economics and policy. Harkin discussed the need for a more integrated approach to health care and what it will take to achieve it, and a panel moderated by Dr. Sean Tunis, represented the viewpoints of insurers, employers, and academia in discussing a range of financial and policy issues necessary for achievement of the visions of integrative medicine. In leading off the summit discussion on economic and policy issues, Harkin noted the brightening prospects for comprehensive health reform. Echoing earlier observations, Harkin and Dr. Kenneth Thorpe reiterated that changes outside the health system (e.g., environmental and food pol- icy) can have a profound effect on health, and reforms in these areas should also be considered and included in health reform discussions. Janet Kahn, among others, suggested greater coordination of health- promoting activities across government agencies, including agencies out- side of the Department of Health and Human Services (HHS). Panelists cautioned that health reform, especially reform emphasizing integrative concepts, is far from a certainty. As a tactical matter, Tom Donohue warned against pointing fingers at other sectors and advised that advo- cates unite around commonly held values. Dr. Reed Tuckson suggested that supporters of integrative ap- proaches should not assume that health insurers will be opposed to their aims in the reform process. Similarly, unlike in previous attempts at health reform, Donohue said, businesses today are supportive of change. For insurers and the business community alike, the dominant concern is rising health care costs. Donohue and William George both viewed the business community as strong participants in reforming the health sys- tem, not only because of their traditional insurance role, but also because 133

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134 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC of their successes with employee wellness models. Some of the more successful models have not only improved employee health, but also have demonstrated return on investment to employers, as described by Dr. Kenneth Pelletier. ECONOMICS KEYNOTE ADDRESS Senator Tom Harkin, U.S. Senate (D-IA) Integrative health care is finally coming to prominence in the United States. For a number of reasons that Harkin noted, the timing for reform seems to be right. Harkin recalled that a few days prior to the summit, President Obama, before a joint session of Congress, predicted that Con- gress would pass a comprehensive health reform measure this year and that the centerpiece of that reform would be a new emphasis on preven- tion and wellness. Harkin observed that Washington has been transformed by new en- ergy and a new sense of purpose, and in no area of public policy is this more dramatic than in health reform. 1 Congress is also moving forward energetically; Sen. Edward Kennedy, chair of the Senate Health Commit- tee, has established a set of working groups to help shape the Senate’s health reform bill. Harkin heads the working group on prevention and public health, which focuses on wellness, disease prevention, and strengthening the public health infrastructure. On the day prior to his presentation, Harkin chaired a hearing on how health reform legislation could be the vehicle to move the nation forward in integrative medicine and to create a culture of wellness. All these signals together, he said, create momentum not just to pass health reform, but to pass “the right kind of health reform.” Currently, payment incentives are biased toward providing conven- tional medical care—patching and fixing people when they get sick, said Harkin. In medicine, what is reimbursed the most is practiced the most; and what is practiced the most is taught in medical schools, thus perpetu- ating the cycle. Meanwhile, alternative therapies, preventive strategies, and integrative health approaches are often marginalized. It is time to think anew, he said, time to “disenthrall ourselves from the dogmas and the biases that have made our current health system in so 1 Harkin noted that he preferred the term health reform, rather than health care reform, because he believes the changes needed are fundamental and systemwide, not merely related to reimbursement.

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135 ECONOMICS AND POLICY many ways wasteful and dysfunctional.” Harkin said that this requires a system that emphasizes care coordination and continuity, patient- centeredness, holistic approaches, and wellness. Such an integrative ap- proach takes advantage of the very best scientifically based practices, whether conventional or alternative. It focuses on improving health out- comes and has great potential to reduce health care costs. Harkin’s belief in the potential value of integrative approaches dates back many years. In 1992, he authored legislation that created the Office of Alternative Medicine at the National Institutes of Health. In 1998, he sponsored legislation to elevate the office to what is today the National Center for Complementary and Alternative Medicine, which one summit participant suggested could be renamed the National Institute for Integra- tive Health Care. Harkin said that the country now faces an historic op- portunity, and “We’ve got to get it right.” He cited Dr. Mark Hyman’s statement in a recent hearing that “we need to rethink not just the way we do medicine, but also the medicine we choose to do.” Another factor that makes such an ambitious effort timely is that to- day, unlike previous attempts at reform, there is broad agreement among ordinary Americans, corporate America, and health care providers that the status quo is disfunctional, wasteful, and increasingly intolerable, said Harkin. The scope of health reform that Harkin envisions would go beyond merely providing health insurance coverage or finding new health services payment methods, important as those issues are. He noted that what we are paying for is as important as how we are paying for it: “It makes no sense just to figure out a better way to pay the bills for a system that is broken and unsustainable.” He said that a reformed system should implement a national prevention and wellness structure; offer a pragmatic, integrative approach to health care; and base reimbursement on outcomes and quality rather than quantity. Without this orientation, any reform effort will fail the American people, he said. Health reform should touch many aspects of people’s lives, espe- cially outside the health sector. Harkin noted that health reform must en- compass health and include consideration for providing better nutrition in schools and exercise opportunities in the built environment, such as sidewalks and bike paths; it should encourage wellness programs in workplaces and community centers; it should provide opportunities for wellness services, exercise, stress reduction, and socialization in our sen- ior centers; and it should make widely available the informational, screening, and counseling programs that help people take charge of their own health. Harkin also chairs the Senate Agriculture Committee, which

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136 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC this year will consider reauthorization of the Child Nutrition Bill. It, too, can contribute to health reform by ensuring that school children have healthier food choices. If, as Andrew Weil says, the default status of the body is to be healthy, then the default status of public policy should be to facilitate that natural process and promote health and prevention, commented Harkin. Physicians and a full range of other health care professionals, as well as teachers, physical trainers, counselors, and others, all have a role to play in assuring both the physical and mental health of our population. Good mental health is critical to good physical health and well-being, said Harkin; any number of physical ailments start, often in childhood, with mental, emotional, or behavioral problems—stress, lack of emotional support, addiction. These problems may worsen over time and, left un- treated, have serious consequences for health, relationships, educational attainment, life skills, and work performance. Harkin reaffirmed his commitment to do all he can to change the na- tion’s health system and place integrative health care at the heart of the 2009 health reform efforts. He encouraged summit participants to follow the debates and discuss these issues with family, friends, and colleagues. He added a note of caution: Just because integrative health care is the most commonsense, rational, health-effective, and cost- effective approach to reform, does not mean it is a done deal. Nothing in this town is done easily, and there are tremendous entrenched forces and vested interests that will defend the conventional allopathic medicine with all their power. The kind of reform he envisions will not happen unless people speak up for it; he emphasized that everyone is a key player in supporting these efforts, so his message is “Seize the day.” Discussion Following the keynote presentation, several members of the audience offered their thoughts on how the current health reform discussion could be shaped to advance integrative medicine and improve the health of the nation.

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137 ECONOMICS AND POLICY Nutrition and Children’s Health The first participant, a nutritionist, asked about the possibility of in- cluding in the child nutrition bill a requirement that schools have hygi- enic, operable water fountains, so that water could be a healthy alternative to sugar-laden soft drinks. Another participant suggested in- creased emphasis on reducing high-fructose corn syrup and increasing omega-3 fatty acids in the American diet. Harkin, who has worked to get healthier foods into schools and eliminating unhealthy choices from school vending machines, recognized the participants concern and described one pilot program that was intro- duced in the 2001 Farm Bill. The program was designed to ensure that children had freely available fresh fruits and vegetables throughout the school day, not just at lunch. The program began with a $4 million budget and was implemented in 100 schools across four states. It has been wildly successful with school administrators, parents, and students, and with Harkin’s leadership the program was expanded to $1 billion in the most recent Farm Bill. Over the next five years 90 percent of students enrolled in free or reduced lunch programs will have access to free fresh fruits and vegetables. Comparative Effectiveness The recent economic stimulus legislation included funds to support comparative effectiveness research for health care practices, and several participants iterated the importance of including integrative approaches in these comparisons. Harkin emphasized that the goal of this research is to reduce the cost of the health care system and improve quality and out- comes of care. He noted that the research will not just look at the current system and approaches to care, but that it will also look at other modali- ties that are available, such as those described by Ornish. Ideally, the re- sults of this type of research will provide information and evidence that can be used by individuals in the decisions they make about their own care.

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138 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC PANEL ON ECONOMICS AND POLICY Panel Introduction Sean Tunis, Center for Medical Technology Policy Panel moderator Tunis noted that his background is not in integrative medicine but that his past work as chief medical officer for Medicare and current work as head of the Center for Medical Technology Policy has made him a realist. He reiterated Harkin’s statement that just because health reform and its inclusion of integrative approaches make sense, does not mean it is inevitable—such significant changes will face formi- dable challenges. Tunis said that summit participants should take the opportunity to become effective advocates, to engage in the debate, and to focus their energies on the most promising avenues for change. Many aspects of potential health reforms will affect the future of integrative health care. For example, reforms that tie reimbursement to outcomes will reflect not just how much practitioners do, but the extent to which their contribution actually improves patient outcomes. When financial incentives are set, someone, at some point, will define which patient outcomes matter. Tu- nis said that integrative health care practitioners will want to be part of that critical discussion. Generally, Tunis observed, integrative medicine has been absent during the push toward comparative effectiveness re- search, and advocates for integrative health care need to work to assure that integrative approaches receive adequate attention as this type of re- search moves forward. Tunis noted that this panel was designed to explore the challenges and the solutions, mechanisms, strategies, and tactics that will help en- sure that integrative health care becomes a key component of a newly reformed health system. Economic Burden of Chronic Disease Kenneth Thorpe, Emory University Thorpe opened with an array of statistics that exemplify challenges in the current health reform debate. He noted that three-fourths of U.S. health care spending is for patients with one or more chronic conditions, which makes these disorders a prime target in efforts to improve the quality and affordability of care. Obesity rates in the United States have

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139 ECONOMICS AND POLICY doubled since the mid-1980s; this increase alone accounts for about 30 percent of the subsequent growth in health care spending and costs about $220 billion a year. Further, for every dollar we spend on medical care costs linked to chronic illnesses, we lose another $4 in productivity. While heart disease caused the largest increase in Medicare costs be- tween 1987 and 1997, it is no longer even in the top five cost contribu- tors, which are: diabetes, asthma, pulmonary conditions, arthritis, and back problems—health problems, like heart disease, that can, in many cases, be linked to personal lifestyle. Thorpe observed that, with this president and this session of Congress, there is a greater opportunity to put together a coordinated, administration-wide policy on prevention. Currently, numerous uncon- nected and uncoordinated programs operated by HHS and other federal agencies offer different ways to intervene to promote health and prevent disease. Organizing these programs in a coherent, thoughtful way could have a tremendous cumulative impact. To improve health care outcomes and reduce costs for the large number of Americans with chronic conditions requires actions outside the traditional physician’s office. Thorpe noted that today’s patient popu- lations and their clinical characteristics are very different than when Medicare was enacted, and many of the services patients need most are not necessarily services that must be provided by a physician. However, the reimbursement system is based on benefits designed four or five dec- ades ago and does not accommodate these needs. Policy makers must figure out how to encourage and cover both nonphysician services and team-based care, said Thorpe. Large systems, like the Mayo Clinic, Geisinger, and Kaiser Perma- nente have solved some of these problems. However, most Americans do not obtain their health care through sophisticated, integrated group prac- tices. In fact, more than 80 percent of U.S. physicians practice in ones and twos, and these small practices account for about 40 percent of the nation’s primary care capacity. Thorpe said that strategies must be de- vised to transfer to the small-office setting some of the functionality and useful components that make those large models effective. Senator Bau- cus, for example, is focusing on delivery system innovations. One model under consideration is to assemble community health teams that include nurse practitioners, social workers, behavioral health workers, and nutri- tionists that can collaborate with an area’s small physician practices and provide care coordination, primary prevention, and community-based outreach services. Lessons can also be learned from innovative state-

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140 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC level approaches to reform such as those in Vermont, North Carolina, Rhode Island, and Pennsylvania. These models frequently factor in community-based prevention strategies and small physician practices. Insurer Perspective Reed V. Tuckson, UnitedHealth Group Tuckson reminded summit participants that health insurance compa- nies such as UnitedHealth Group have agendas and missions that are well aligned with the summit’s goals. Many insurance companies work hard to ensure responsible policies for prevention, wellness, and inte- grated care, he said. In fact, UnitedHealth Group views itself as “a health and well-being company”; for example, the company spends millions of dollars to collect and analyze data, in order to identify individuals’ risk factors for disease, then provide them with a variety of individually tai- lored support services to assist in personally appropriate preventive in- terventions. It also uses its data to identify gaps in care; conducts sophisticated analyses to assure that individuals have received appropri- ate care; provides evidence-based guidance to individuals through their preferred electronic or print vehicles; and facilitates access to health coaching from trained clinicians. Tuckson said that these are just some elements of the company’s patient-centered care capabilities that are de- voted to enhancing health and wellness for each individual. From an insurer’s perspective, one of the most significant barriers to expanding integrated health care is the unsustainable escalation in health care costs. One major contributor to that cost escalation, he said, is “Eve- ryone wants everything all the time.” As more people experience pre- ventable chronic illnesses, as increasingly expensive pharmaceuticals and technologies are developed, and as consumer demand remains insatiable, health care costs will continue to be challenging, according to Tuckson. Financing for new interventions and for services associated with integra- tive medicine will present new challenges, he said, especially until re- searchers produce convincing evidence of clinical and cost-effectiveness. Concerns about the quality of current clinical care delivery form an equally challenging context for the introduction of integrative medicine, said Tuckson. Research indicates that almost half of clinical care deliv- ery today is inconsistent with prevailing evidence-based guidelines. In the case of new (often expensive) technologies, the criteria for clinical appropriateness are often weak, and deviation from the available evi-

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141 ECONOMICS AND POLICY dence is a frequent concern, noted Tuckson. Additionally, at an alarming rate, individuals fail to exercise personally appropriate health protecting and enhancing behavior; almost 21 percent of the population continues to smoke; the incidence of diabetes is increasing rapidly; and the prevalence of obese children is such that 32 percent of children and teens are over- weight and 16 percent are obese. Within this context, in order to gain acceptance for integrative health care, advocates must have a realistic organizing vision for what they are trying to achieve, how integrative services will be implemented, what the roles and scopes of practice are of key disciplines, and what the evalua- tion criteria are, said Tuckson. Decisions regarding the incorporation of proposed interventions must inevitably be grounded in evidence of effec- tiveness, and arguments about the difficulty of accumulating this evi- dence will not lessen the importance of this critical information. Advancing integrative health care will also require answers to a series of critical questions that Tuckson posed to the plenary session: Who pays for prevention? What are the relative roles of public, private, and individual resources? How can population-based prevention efforts be effec- tively coordinated with individual preventive initiatives? How can synergies be maximized? Should the staffing of new patient-centered multidiscipli- nary preventive care be static or fluid to meet case-by-case challenges? How are different members of the comprehensive care team trained, credentialed, evaluated, coordinated and re- imbursed? What are ways to prevent redundancy and maximize efficiency? What is the health return for employers’ investments in in- tegrative health care? Finally, Tuckson said that the new integrative health team will re- quire new coding systems in order to capture the services they deliver and new health information technology infrastructures that can record and enable assessment of their work on behalf of the unique needs of individuals. Tuckson concluded his remarks by committing UnitedHealth Group to actively participate in the exploration of the questions noted above,

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142 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC particularly those related to acquiring the evidence necessary for advanc- ing this important field. Business Community Perspective Thomas J. Donohue, U.S. Chamber of Commerce The U.S. Chamber of Commerce represents three million companies, which gives the organization a strong interest in health care. The main health care concern for the business community today is that health care simply costs too much, especially for the growing number of retirees, said Donohue. Thorpe said that Medicare patients are different today than in the mid-1960s, and there are a lot more of them, said Donohue. When Medicare was enacted, actuaries estimated the average American’s lifespan at 62.5 years. Now, Americans who reach 65 live nearly two more decades, on average. This puts a tremendous strain on companies with growing numbers of retirees, and it creates serious dislocations in industries that employ far fewer people than they used to in order to ac- complish the same—and more—work. The fundamental change needed in this country, particularly for health care, is to stop blaming everyone else, said Donohue. The prob- lems of our current system are not caused by health care providers or the insurance companies. “We are only willing to pay them so much, and as Reed indicated, we want every service available to man,” he said. To successfully move forward, everyone—corporations, hospitals, doctors, professional practitioners of every type, and insurance companies—must be involved in the reform debate. The best strategy, he said, may be to identify and unite around com- mon issues that everyone agrees to and can support. Wellness is one. Another is the need for serious health information technology, not only to find out which treatments work, what the best practices are, and where people get the best results, but also to run complex health care systems. Most important, he said, almost everyone can agree that there has to be a way to cover people who do not have health insurance, because care for uninsured people is being provided at an unnecessarily high cost. Yet, there are issues where agreement will not come easily, including how to divide finite health care dollars. Donohue said that every advo- cacy group should understand that “You are a petitioner. You want your piece of the pie. The biggest thing we all have to worry about . . . is, how much pie is there? How much pie can we afford?” He cautioned that so-

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143 ECONOMICS AND POLICY ciety cannot bear the cost of a grossly expensive system created by peti- tioners, and that infighting cannot be allowed to negatively affect the issues having widespread support. Donohue predicted that the business community will ultimately be supportive during the upcoming reform debates, because businesses are under severe pressure to change the status quo. In fact, he said, business can be a strong partner in reform efforts, building on the strengths of the employer-based health insurance system, which covers some 150 million Americans. Another strength offered by business is the investment many employers have made to develop a healthier workforce. They understand that healthier workers are more productive and reduce the employer’s short- and long-term medical costs. Donohue noted that the nation’s di- verse workplaces are useful laboratories for experimentation with new models of care and are contained environments for measuring results. Because of the employer-based system’s record of innovation, meas- urement capacity, and motivation to achieve many of the wellness objec- tives described at the summit, Donohue supports continuation of the employer-based insurance system over a single-payer model. Employer Perspective William W. George, Harvard Business School George said “The employer-based system is the strongest part of our health care system,” and that integrative health care is the key to its fu- ture. In fact, George said that it will not be possible to offer health insur- ance to 100 percent of Americans unless we have a health system that promotes wellness and prevention. George noted his belief that employers have a role and responsibility in health promotion and disease prevention. Employers—especially those in the health care field, which in many communities are the area’s largest employers—should serve as role models for customers and patients. Ways to do this include hospital food services that offer only healthy choices and no-smoking policies that cover a health facility’s entire property, including parking lots. The goal for employers that emphasize wellness is not achieving the lowest cost; it is to have 100 percent of em- ployees fully present on the job every day—in other words, improved productivity. Company CEOs need to take initiative and active leadership on health care matters and not delegate them to unions, health plans, or

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144 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC company benefits managers, said George. Instead, business leaders need to invest time on health care issues, make serious attempts to reduce pa- perwork that drives up costs, and recognize that employee health is tightly linked to company strategy and productivity goals. As an exam- ple, he said that Target stores find a direct correlation between the health of their employees and customer satisfaction. The stores where employ- ees are healthiest have the highest customer satisfaction ratios, as well as the greatest revenue growth. George also said that business leaders need to devise ways to engage employees in their health and empower them to take responsibility for it. The full range of wellness services that employees need starts with a cor- porate culture where health is something that is honored and enjoyed. This culture could include having nutritionists on staff whom employees can talk to as necessary; offering stress management options, support groups, and health coaches; and having a fitness center. These are not “perks,” he said—they are services that are important to health, and the workplace is one of the most convenient places to offer them. He also suggested that a great deal of support can be provided online with social networking, and that this support should be made fun. Employees who are pregnant or have chronic conditions may require additional support and active management, some of which can be pro- vided at work, said George. When employees need hospitalization, the employer should encourage treatment in designated centers of excel- lence, because of the direct correlation between volume and quality of care and, therefore, long-term costs. Even with all these employer-provided options, the basic premise still must be that employees are responsible for their health. George said that the role of employers is to give employees the resources and, per- haps, even provide financial incentives for wellness. For example, em- ployers could offer incentives for maintaining a healthy weight, healthy cholesterol levels, or practicing healthy behavior, like not smoking. If employers took on these suggested roles, there would not need to be as many government health reforms, said George, although govern- ment should require portability of health plans, so that when people change jobs they can take their health plan with them if they choose. George supported pretax health insurance coverage for every American and development of private insurance pools for small groups of employ- ees, employees without health coverage, and the unemployed, so that everyone can have access to health opportunities typically offered by large companies.

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145 ECONOMICS AND POLICY In conclusion, George also warned against blaming others, described by Donohue. Rather, he endorsed making integrated health care the core of our nation’s system and building on employer capacity, “so that well- ness and prevention become the essential characteristic of every work- place in America.” Behavior Change Incentives and Approaches Janet R. Kahn, Integrated Healthcare Policy Consortium Kahn began by building on prior discussions of summit speakers and participants, noting that a broad range of disciplines is involved in inte- grative care. For true integration, these diverse practitioners must be knowledgeable about and respectful of one another’s expertise and col- laborate effectively in the interest of their patients, said Kahn. Integrative health care need not depend solely on doctors to do patient-oriented, mind–body care; rather, it should take full advantage of the existing ex- periential base of qualified providers. 2 This would allow patients real choice about the kind of provider they use. Moreover, making better use of the full range of providers who can serve in a primary care role— nurse practitioners, physician assistants, naturopathic physicians, and others—would help reduce the current primary care physician shortage. In Vermont, for example, naturopathic physicians are now classified as primary care providers and are reimbursed by Medicaid, providing the opportunity for a natural experiment. In general, states’ authority to set scope-of-practice laws produces interstate differences in practice pat- terns, providing a valuable opportunity for comparative research on mechanisms for delivering primary care services. At the federal level, Kahn said that a single entity should be respon- sible for coordinating integrative health-related policy efforts across agencies, perhaps through an Office of Integrative Health Care and Wellness. That office could be charged with scoring domestic policy proposals—not just those within HHS, but across the executive branch, including those related to education, transportation, the environment, housing, and agriculture—as to their potential impact on health and ill- ness, just as the Congressional Budget Office scores the potential finan- cial impact of all proposed legislation. 2 Kahn noted that the term qualified refers to providers who are licensed and have been educated at institutions that are accredited by a Department of Education-recognized accrediting body.

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146 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC Kahn noted that social scientists have demonstrated that it is rela- tively easy to enhance someone’s knowledge about a behavioral health risk and slightly more challenging to help them shift their attitudes to- ward it, but that getting someone actually to change their behavior can be very difficult. Individuals have to decide not to smoke or not to eat junk food, not once or twice, but multiple times daily. There is no one best way to accomplish successful behavior change for everyone. Even with solid evidence of effectiveness for such interventions as smoking cessa- tion, potential program sponsors need to know exactly how such pro- grams should be implemented for their target population, and what their return on investment will be, said Kahn. Clearly, health professionals do not change other people’s behav- ior—individuals must change their own behavior. However, health pro- fessionals can promote these changes with policies, incentives, and media messages that persuade people they want to change. While indi- viduals do the hard work of changing what they eat and how they exer- cise, health professionals can provide emotional support for the individual trying to change, whether they achieve their goals or not. If they did not do it this time, they might the next. Opportunities to facilitate behavior change are all around us. People are social beings embedded in networks—from preschools to workplaces to retirement homes—and health professionals should work in those networks to encourage behavior change. Also, people live in both natural and built environments that are dramatically different across the country and vary across class lines. These environments can be improved to make exercise easier or healthier food more available. The workplace offers many possibilities for behavior change, includ- ing a wide range of incentives and rewards, such as those previously de- scribed. Incentives in the workplace do work and can offer an opportunity for cost containment. Kahn noted that some companies have been able to reduce their annual increase in health care costs to 1 percent, rather than the average 8 or 9 percent. But incentives can backfire, Kahn warned. Some employees may feel that these incentives, which require the regular collection of health information, impinge on their privacy. Workplaces that have been most successful have coupled financial incen- tives with team building and social support for behavioral change. Central to success of behavior change strategies, whether across so- ciety or within a single workplace, is the use of multiple message chan- nels and the alignment of these messages with policies. Kahn cited smoking cessation as an imperfect, but highly successful effort at health

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147 ECONOMICS AND POLICY behavior change. In the United States in 1965, roughly 51 percent of men and 34 percent of women smoked. By 2005, rates of smoking dropped to 24 percent of men and 18 percent of women. Interventions that facilitated this change involved a coordinated health policy effort that included ap- proaches ranging from increased taxes on cigarettes, to municipal regula- tion of where people could and could not smoke, to nicotine patches and workplace smoking cessation programs. 3 Within a corporation or within a country, policy makers should not be talking about health and wellness on one hand while creating situa- tions that lead to unhealthy behavior on the other, said Kahn. On the pro- vider side, financial incentives encourage use of expensive interventions rather than prevention strategies. Incentives encourage medical students to pursue specialty rather than primary care careers. Equally powerful incentives for prevention and health should be purposefully reset, she said. The goal, suggested Kahn, is to encourage people to want to change their behavior, and then to be prepared to help them when the point of wanting to change. This requires a state of readiness on the part of the employer, public health system, health care providers, and others, and this involves both removing barriers to change and having programs and systems that can provide necessary support. One aspect of this can be incentives that can make change worth it in multiple ways including fi- nancially and socially. To make healthy behavior normative, Kahn said, incentive structures must be aligned, not working at cross-purposes. Rewards of Integrative Medicine Kenneth R. Pelletier, University of Arizona School of Medicine and University of California (UCSF) School of Medicine Analyzing the economics of integrative medicine defies easy eco- nomic analysis. When people approach such a difficult topic, they tend to turn to tools like cost–benefit analysis, with its aura of precision, said Pelletier. Cost–benefit analysis is a complex field with perhaps a dozen different alternative methods, all of which can provide useful informa- tion. These include cost–benefit analysis, cost-effectiveness analysis, 3 Kahn noted that Dr. Kenneth Warner, Dean of the School of Public Health at the Uni- versity of Michigan, has authored a chapter entitled “Tobacco Policy in the U.S.: Lessons for the Obesity Epidemic” describing coordinated approaches to improving health (Mechanic et al., 2005).

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148 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC assessment of net present value, return on investment, and econometric modeling, which can encompass all of the previous techniques. Different cost–benefit methodologies reflect different perspectives. They often result in incomparable and even nongeneralizable outcomes. A systematic review conducted by Pelletier and colleagues provided sev- eral insights about these differences as they apply to integrative medicine (Pelletier et al., unpublished). Researchers examined all the definitions of the patient-centered medical home, chronic care management, extended primary care, and integrative medicine, and found that the various defini- tions have more in common than not. One of the distinguishing factors of integrative medicine was that, in the majority of definitions, it included evidence-based alternative medicine. The researchers decided to examine what cost–benefit analysis would look like when applied to this distinguishing characteristic. They conducted an international literature search that yielded 59 cost–benefit analyses, 39 of which were considered full evaluations. From these, they identified eight alternative medicine modalities that appeared to be cost- effective in treating various conditions, including acupuncture, guided imagery, relaxation, and various forms of meditation. One specific cost- effective modality/condition pair was use of acupuncture for migraine. While integrative medicine is clearly not synonymous with complemen- tary and alternative medicine (CAM), this research showed that there are CAM components that are likely to be cost-effective in an integrative care model. Pelletier has dedicated time to managing clinical trials in various worksites, and he noted that corporations are perfect sites for implement- ing and evaluating integrative medicine. First, employers call people people not patients. He said that corporations have a vested interest in the health, performance, and well-being of their employees, while they have no vested interest in disease. Additionally, employers are not wed- ded to certain modalities of treatment, as long as it is effective in terms of clinical and cost outcomes. If, for example, an employer learns that acupuncture for back pain is superior to surgery, they would support the use of acupuncture. Pelletier reported on research that identified 153 clinical and cost outcome studies of worksite integrative health approaches (Pelletier, in press), all of which have demonstrated net benefits in terms of short-term and long-term disability, absenteeism, general retention, key personnel

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149 ECONOMICS AND POLICY retention, productivity, performance, and presenteeism. 4 Of the 63 stud- ies that used cost–benefit analyses, all but one older study showed posi- tive results, and 24 reported a return on investment—the hard-to-reach measure that is the gold standard within the business community. The most conservative return-on-investment result that would be considered positive is 1:1. Many people in a corporate environment would be very happy with a dollar-spent:dollar-value-recouped return, he said. But the returns on investment found in this literature ranged from 3.5–4.9:1. These are salient results, because the return on investment does not have to be very high for the dollar savings to be large. Pelletier also noted that, on average, rate of return outcomes were most evident after approximately 3.25 years, suggesting that these types of employer investments should be long term. The potential for such persuasive results indicates that cost–benefit analyses should be included in assessments of integrative medicine pro- grams, especially effectiveness trials. Pelletier predicted that integrative medicine and its preventive components will prove to be dramatically more cost-effective than many conventional services, at least on a purely empirical basis. He also agreed with Donohue and George that employ- ers have a large stake in both ensuring employee health and involvement in health and medical care reform. Pelletier said that within 2 to 3 years it should be possible to create a minimum set of standardized measures that could be used to assess any and all health services that purport to be safe, effective, and cost- beneficial. This would provide a basis for more accurate comparison of integrative and conventional care approaches. The problem in the na- tion’s medical care sector, which currently spends $2.5 trillion annually, is not that it needs more money. The problem is that these resources are misallocated, he said, because many of the services and interventions that are regularly paid for would not pass any of the measures of cost- effectiveness. By conducting appropriate cost–benefit analyses, Pelletier said it will be possible to create an evidence base for allocating health care resources in a more scientific and cost-effective way. 4 Presenteeism measures the ability of a person to be present at work, both physically and mentally.

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150 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC Panel Discussion Members of the panel responded to questions from the audience in a discussion moderated by Tunis, who began the discussion by repeating what he called “a great truism about Washington,” which is that when everyone seems to agree on any policy idea, it usually means it has not been defined specifically enough. Tunis noted that the summit had en- gendered much agreement on what needs to be done to promote the adoption of integrative health care, and he encouraged participants to dive into some of the details. Evidence for Integrative Medicine Participants asked how much and what kinds of additional evidence would be needed to make integrative health care approaches more widely accepted. Given how much evidence had been presented at the summit, it seemed to some participants that there should be more forward progress in terms of adopting and reimbursing clearly effective programs. One of the accomplishments of the summit is that it made available some of these studies, Tuckson said. Much of the research presented is not well known outside the integrative medicine community. He said that it needs to be examined closely and then disseminated more widely. Be- cause so few people are familiar with this body of research, they will challenge it, Tuckson warned, and it must meet the scientific scrutiny that should be applied to all interventions. Obtaining definitive evidence about prevention can be difficult and can require a significant amount of time. However, when it comes to prevention and wellness, George said, we simply cannot wait for ran- domized trials to prove that modalities such as meditation and fitness and diet and nutrition work. He noted that there is evidence to support them now, and they should be put into practice and measured after the fact. “This may not fit the pure scientific model,” he said, but if you can show employers cost–benefit data after the fact, they will continue supporting these programs.

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151 ECONOMICS AND POLICY Evidence for Conventional Care Another participant countered that much of conventional, allopathic medicine has never been proved effective, yet billions of dollars are spent on it, creating an evidentiary double-standard. According to Tuckson, the most important driving force in the health care industry today is performance assessment. Anyone associated with organizing or paying for health care benefits is frustrated with the vari- ability in quality of care, he said. This is especially important to patients, as they increasingly are expected to participate actively in selecting the physicians and hospitals they use. This scrutiny creates enormous tension in the allopathic community, Tuckson said, but ultimately, these efforts will lead to a much closer connection between reimbursement and per- formance. Moving forward, the system will need to find performance measures that emphasize outcomes more than process. Although this field is not very mature yet, it is moving rapidly. Integrative Medicine and Models of Reimbursement A participant described the difficulty in obtaining full reimbursement for the integrative medicine services she provides. Tunis said that her question raises the issue of whether a reformed system would approach integrative services in the old fee-for-service way or adopt some alterna- tive. Worksites have developed some generalizable alternative models, Pelletier said, that work in the community and draw on community re- sources. These models are entirely dependent on networks of providers. For example, Cisco Systems recently built a patient-centered medical home within its corporate headquarters that is linked to day care and cor- porate health services. It includes evidence-based alternative medicine, uses an electric medical record, and has an on-site pharmacy. Use of the Internet for telemedicine applications also will enable some interesting hybrid approaches, as will use of health coaches to reach out into the community. When it comes to reimbursement, Pelletier said he would advocate very strongly for adequate compensation for primary care. Reimburse- ment problems continue to be difficult, Tuckson acknowledged, saying, “Let’s be excited about trying to answer [the questioner] in a way that is affordable and sustainable to the health system and fair to practitioners.”

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152 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC PRIORITY ASSESSMENT GROUP REPORT 5 Helen Darling provided the report of the priority assessment group that focused on the economic incentives of integrative medicine. This summary includes the priorities discussed and presented by the assess- ment group to the plenary session for its discussion and consideration; these priorities do not represent a consensus or recommendations from the summit. In discussing this area, the group decided that its first priority relates to the big picture: figuring out how to go from an unhealthy to a healthy America. This means not only determining the steps that need to be taken, but also deciding which ones society wants to pay for collectively. The summit discussions have described many valuable types of treat- ment, supported by a growing body of evidence, yet many are not cov- ered benefits under most insurance plans so are not reimbursed fully (if at all), and must be paid for by the consumer. The second priority identified by the group was the need for an or- derly, ongoing process to make decisions related to which new integra- tive services will be reimbursed. It is not enough to assert that insurance should pay for these services, since the public, through premiums, taxes, or lower wages, is the ultimate payer. We have to somehow decide to- gether what services are safe, effective, cost-effective, and have added value. Care delivery needs to be organized better, possibly through team- based approaches, and paid for based on outcomes, not just individual services. The group suggested that perhaps teams can be paid on a capi- tated basis, enabling them to decide how to produce the most health for society’s investment. To bring appropriately trained people into teams may require programs like one in Washington State that provides loan forgiveness for integrative care practitioners who serve 3 years in under- served communities, as one participant in the group suggested. The third priority was to consider integrative medicine a solution, not an add-on. Reimbursement decisions are difficult, and not every service, intervention, or modality of care can be paid for. If the system does not identify low-value, wasteful, or harmful services to eliminate, it cannot recoup the nearly $400 billion needed to provide coverage for the cur- rently uninsured population. However, the push for cost-control may turn 5 See Chapter 1 for a description of the priority assessment groups. Participants on this assessment group included Sean Tunis (moderator), Helen Darling (rapporteur), Eric Caplan, Robert DeNoble, Erminia Guarneri, Patricia Herman, Davis Masten, Anne Ne- drow, William Rollow, Richard Sarnat, and Michelle Simon.

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153 ECONOMICS AND POLICY out to be a strong incentive to adopt integrative approaches, particularly if Americans understood that these approaches are being advocated not because they cost less, but because they produce superior results. The group’s fourth priority was to incentivize organizations outside the health care sector—schools, communities, employers, and consum- ers—to provide effective care, defined broadly. This is a way to reallo- cate existing resources to achieve greater health benefit. Key roles in achieving these priorities would be played by Congress and the new administration, as the nation tries to move quickly toward national health reform. Insurance companies and state governments also have important roles. They will decide what they will pay for. Other key actors identified include the broad group of health care clinicians and researchers. And, certainly nothing will work if consumers and patients are not engaged, informed, and supported in efforts to achieve some con- trol over their own health. The two next steps the group identified were to catalog successful in- terventions and models under way around the country for both ideas and inspiration; and second, to expand and diversify the types of evidence and research used to assess integrative health care approaches.

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