Among its peculiarities, Section 2706 of the Affordable Care Act – which prohibits health insurers from discriminating against licensed providers -- draws its language from the 1995 law that established the Medicare Advantage program. Does this mean Medicare Advantage has covered beneficiaries’ treatments by licensed acupuncturists, naturopathic physicians, massage therapists and others since 1995? In a word: no.
In fact, Sect. 2706 non-discrimination provisions do not include Medicare or Medicaid services. To the integrative health and medicine communities this has been a serious omission, because the qualities, outcomes and advantages of many integrative treatment approaches have been shown to be highly suited for the treatment of the chronic, multi-faceted and costly conditions of ill health experienced by beneficiaries of both Medicare and Medicaid. They are also suited to the current economic objectives of HHS and its Centers for Medicare and Medicaid Services (CMS) to drive US-economy-saving reductions in the costs of care.
So where there appear to have been conditions for a confluence of cost savings and beneficial outcomes for CMS beneficiaries, dating back to 1995, instead there remains a lingering disconnect between need and available care options. As we will see though, hints of this confluence remain.
Integrative Care: Making the Cut, but not the Team
In April 2016, an article from Kaiser Health News via Altarum Institute, "Innovation Center Tries to Reinvent Medicare", described the work of the Center for Medicare and Medicaid Innovation, CMMI. Like Sec. 2706 a creation of the ACA, CMMI has funded scores of projects designed to establish Alternative Payment Models that are based on "value" in order to achieve CMS goals for Medicare and Medicaid: reducing the costs of treatments and services and keeping patients healthy.
The article described two types of care scenarios for which integrative treatments have shown success: the first with acupuncture; the second with naturopathic medicine:
- Hospitals in 67 major metro areas are accountable for costs and quality for hip and knee replacements, the most common inpatient procedure for Medicare patients.
- A "Comprehensive Primary Care Plus" initiative that will provide upfront payments to 5,000 medical practices to coordinate care.
In an email to CMMI Chief Medical Officer Patrick Conway, MD, I referred to the article and noted 2012 research from Britain that reported the use of acupuncture as a treatment option for a segment of a group of patients slated for knee replacements. The resulting savings from acupuncture treatment averaged some $8000+ per patient compared to those who went through with the surgery.
In mid-July, along with Mike Jawer, Director of Government and Public Affairs of the American Association of Naturopathic Physicians, AANP, I visited CMMI in Baltimore to learn whether and how integrative practices were involved in its Alternative Payment Models programs. We met with a team of senior CMMI program managers and presented examples of the use and adoption of cost-saving integrative treatments across US healthcare, including in large systems like DOD and the VA, in hospitals and medical schools, and in some state Medicaid waiver programs. Mr. Jawer described both AANP's proposed pilot for CMS funding for cardiovascular treatment and its survey of older Americans that reports their preferences for naturopathic care. We also provided the important compilation of cost-effectiveness research produced in 2015 by the Integrative Health Policy Consortium, IHPC, "Integrative Health and Medicine: Today’s Answer to Affordable Healthcare.”
Nevin Laib of CMMI's Stakeholder Policy Division observed that we had "made the case" about costs and efficacy, but then told us that CMMI had completed its funding rounds for alternative payment models. We felt two years too late.
Although the application period had come to an end, the CMMI team was clearly interested in and knowledgeable about the qualities of integrative treatments, several from personal experience. Mollie Howerton, Ph.D., of the Preventive and Population Health Care Models Group, Health Care Innovation Awards (HCIA) and lead on CMMI's Diabetes Prevention Program, previously worked at the National Cancer Institute where she observed good outcomes from integrative oncology. Someone actually used the term "confluence" to describe CMS goals and integrative treatment potentials. The integrative community was encouraged to reach out to alternative payment model pilot awardees and discuss the possibility of adding integrative therapeutic options to achieve their cost-savings goals.
(And despite CMMI's programmatic boundary, AANP has continued to work with members of Congress to support its proposal to CMS to fund a pilot project, "assessing the health benefits and cost savings of naturopathic care for seniors at risk for cardiovascular disease." In late September representatives Mark Pocan (D-WI), Chellie Pingree (D-ME) and nine other House members signed a letter to Dr. Conway at CMMI supporting the initiative.)
Informing the Confluence
The CMMI team asked to be kept informed of activities supporting this notion of confluence. Apart from those ghostly 1995 non-discrimination provisions in Medicare Advantage, more recent notable examples are the state Medicaid-waivered-pilots created to bring integrative therapies to the treatment of a variety of specific conditions. These include:
- Oregon: In the summer of 2016, beneficiaries of Oregon's Medicaid program, Oregon Health Plan (OHP), for the first time began covering access to back pain treatment options “with less reliance on medication and fewer costly surgeries.” These options include acupuncture, chiropractic, cognitive behavioral therapy, osteopathic manipulation, physical and occupational therapy, yoga, intensive rehabilitation, and massage.
- Vermont: In July 2016, the state enacted its Opioid Bill, which includes $200,000 for a Medicaid pilot to use acupuncture as a non-opioid, pain management option, slated to start next year.
- Rhode Island: The results of a three-year, Medicaid-funded program were delivered to the state in June and its public availability is pending. A Medicaid waiver here was established for the use of integrative treatments for patients suffering the most difficult, chronic, co-morbid and costly conditions (more below).
- Florida: The Rhode Island project was patterned on Florida's experience. Starting in 2003, Florida established the first Medicaid waiver pilot to make use of integrative therapies. Managed by then Alternative Medicine Integration of Chicago (now Advanced Medicine Integration), the Florida program focused on improving quality of care and cost-effectiveness in disease management, including chronic pain for patients in the Tampa area. The outcomes were successful enough that the state legislature renewed the program in 2007. (It was not renewed after the second phase when Medicaid management arrangements were changed; the integrative therapeutic programs were discontinued).
(For reporting and analysis on the Florida pilots see the links at the end of the article.)
The Rhode Island project was established to treat the most difficult and costly Medicaid patients. They were organized into "Communities of Care" by UnitedHealthcare, which manages the state's Medicaid program and which sub-contracted the Medicaid project to AMI. In the state's Medicaid program, these patients reportedly cost 10 times more than standard enrollees.
An early indication of results can be seen in newsletter articles UnitedHealthcare produced during the pilot period:
- A patient suffering from debilitating conditions including a gastric ulcer, eczema, insomnia, depression and chronic pain experienced progressively better outcomes in a treatment period of two years, during which monthly costs of care fell from more than $950 to $99.
- An isolated patient beset by dental and vision problems, obesity, chronic back pain and osteoarthritis and resultant oxycodone addiction was assisted by a holistic nurse case manager who earned the patient's trust and over time "turned her life around," which now includes skipping the emergency room and no longer needing oxycodone.
In the spring of 2016, an early summary of the pilot's impact on system utilization was reported by Traci Green, PhD MSc, a professor in the Department of Emergency Medicine at Brown University's medical school at the "National Rx Drug Abuse and Heroin Summit." The image below from her presentation, "Complementary and Alternative Therapies for a Medicaid Population with Chronic Pain," lays out the reduced system use that emerged with the use of non-pharmaceutical treatments ("CAM engagement;" for complementary and alternative medicine):
It is important to note the manner of treatment that has been shown to be successful in these waiver-based integrative care efforts: trusted support by nurse case managers who take enough time (often many months) to help patients unravel years' worth of compounding ill-health symptoms and conditions. As John Weeks, editor and publisher of The Integrator Blog, writes in his analysis of the Florida programs (link below), the treatment variables that produce the outcomes reported from these Medicare pilots "characterize the care a person can be expected to receive in any self-respecting integrative medicine clinic or from any whole-person oriented practitioner."
The team at CMMI was likely not thinking about the manner of care when remarking on the potential confluence that integrative approaches might bring to its financial goals. More to their purposes, data points like that 89% reduction in treatment costs quoted by UnitedHealthcare in AMI's Rhode Island program, even for a single individual, become notable markers along any path to confluence.
The Integrator Blog: Reporting and Analysis on Medicaid Waiver pilots in Florida organized to apply integrative therapeutic approaches.
 - 42 CFR 422.205 – Provider Antidiscrimination Rules
This relationship between the language of 2706 and the legislative language behind Medicare Advantage was observed only recently: in a footnote to the 2015 revised guidance on Sect. 2706 provided by the departments of Health and Human Services (HHS), Treasury and Labor.