Integrative Medizin und Gesundheit

3.2.3 Era 3: Non-Integrated Integration (1995–2010)

A turning point for this activity was a New England Journal of Medicine article, noted in the introduction to this chapter. The January 28, 1993 publication of the results of a nationwide survey from a Harvard University team led by David Eisenberg, MD catapulted the grassroots movement into visibility and onto the pathway to recognition and respect. That 34% of adults were using “unconventional” methods outside the mainstream and spending $ 13.7 billion each year changed the behavior of multiple stakeholders. These data gave the field legitimacy and began to shift behavior in hospitals, among insurers, in reporting in the media, among researchers, and in the interests of elected officials.

Tab. 1 Development of Standards by the Licensed Integrative Healthcare Professions (Clugston et al. 2017; this table is from the Clinicians’ and Educators’ Desk Reference [CEDR] which was developed by the Academic Collaborative for Integrative Health [ACIH, formerly known as ‘ACCAHC’ – https://integrativehealth.org])

* For chiropractors, this category uniformly represents licensing statutes; for naturopathic physicians, this category primarily represents licensing statutes, with a few states offering registration statutes; for acupuncture, virtually all states use licensure; for massage and direct-entry midwifery, there is a mixture of licensing, certification, and registration statutes.

** COMTA Accredited schools/programs. Does not include institutions accredited by non-specialized agency.

*** Although the Council on Chiropractic Education was first incorporated in 1971, there were other accrediting agencies and activities within the chiropractic profession dating back to 1935.

The timing was good. The competitive landscape of medical delivery had begun to promote the idea of “patient-centered care” that had taken root 15 years earlier. Offering some integrative services began to be viewed by some as part of that effort. The competition between hospitals created opportunity for integrative services. Yet at the same time, the abiding mistrust and disdain inside organized medicine led to fundamentally non-integrated strategies for integrating these into their business model. In hospitals, stand-alone integrative centers were favored over initiatives that would foster more dialogue and collaboration. Insurers developed what were called “carve-out” models for coverage. Instead of exploring how inclusion of such services might lower costs and provide better care, they merely charged more to offer additional complementary medicine benefits.

In this time, governmental support of research began, yet also with a non-integrated character. Via political and public interest, members of Congress funded what has now become the National Center for Complementary and Integrative Health (NCCIH). The fit with the non-integrated character was that rather than being the result of curiosity among researcher inside the NIH about the remarkable levels of public use of these complementary and alternative practices like acupuncture and meditation, the new center was essentially forced on the NIH by an alliance of the consumers-as-voters and their elected officials. The combination of public interest, emerging use in hospital centers and coverage by insurers, and then the more direct integration into the dominant school that will be described, led annual funding to of this research to rise from $ 2 million in the first appropriation to $ 145 million in 2019.

This growing availability of research funds stimulated interest in academic health centers. Multiple medical clinicians and researchers with an interest in CAM convinced their institutions to allow them to start new complementary and integrative centers. What is now the Academic Consortium for Integrative Medicine and Health, founded with just 12 members in 2002, grew to 75 North American members by 2020. Envisioning the roles of these new academic entities as combining “CAM” with biomedicine, Andrew Weil, MD, a popular author and leader of what is now the University of Arizona Andrew Weil Center for Integrative Medicine began urging that “Integrative Medicine” be the banner under which the movement should evolve. The integrative era was formally seeded in 1995.

The Internal Reform Effort: From Volume to Value

Another basis of the non-integrative models stemmed from a deeper cause: namely, the so-called “perverse incentives” in the medical industry. The fee-for-service, volume orientation influences hospitals to produce more high-cost, tertiary care procedures and surgeries. Similarly, though counter intuitive, insurers in the US structure, paid as they are on essentially a percentage of premiums, earn more over the long run the higher the costs of care (U.S. Centers for Medicare & Medicaid Services 2020). Neither stakeholder was attracted to rapid uptake of time-intensive, relatively low cost, preventive and lifestyle-oriented integrative service providers whose adherents claimed that more use of their services might reduce the need for high-margin procedures and surgeries.

The potential for openness to integrative strategies in the dominant payment and delivery organizations began to shift as the mainstream of medicine began to reckon with soaring costs – more than double the per capita of most other nations – and with the evidence of harm and inefficiencies. The turning point was the publication from the then Institute of Medicine at the National Academy of Sciences in 2000 of To Err is Human. The report documents that roughly 100,000 people each year were dying from the regular practice of medicine (Kohn et al. 2000). As noted in the introduction, a 2015 estimate put this mortality much higher.

This year 2000 report awakened a reform movement in the dominant school of medicine. Leaders targeting unraveling the causes. Among those called out: the focus on production of services; prioritizing specialty care over primary care; failing to have the patient at the center of care; a top-down medical hierarchy marked by interprofessional abuses; and eventually, realization that the focus needed to shift from merely the management of disease to addressing behavioral and social determinants of health. By the mid-teens, outcomes like wellbeing, resilience and creating health entered the dominant school of medicine’s lexicon (Weinstock 2013; Weeks 2018a). The movement was branded as “from volume to value.” The key values were identified as a Triple Aim: better patient experience, lower costs, and enhance population health. A fourth was quickly added in recognition of the high levels of burnout and suicide in medicine, which was to also enhance the experience of practitioners.

The new values of the movement had remarkable alignment with those of the integrative health movement (s. Table 2). The reform efforts proved to be – to paraphrase songwriter Leonard Cohen’s description of the “cracks in everything, where the light gets in” – openings for Integrative Medicine practices and practitioners to enter more directly into influencing the dominant medical paradigm. The movement for value-based medicine energized the Era 4 movement for Integrative Medicine to form more powerful collaborations and the Era 5 era of convergence.

Tab. 2 Convergence of Interest: Integrative Health and Value-Based Medicine

3.2.4 Era 4: Acting through Consortia and Collaboratives (2001–Present)

The experience of the beginning of inclusion – even if not yet an embrace of these practices and practitioners as potential methods to better treatment or lower the cost of care – stimulated activists in the movement, including the present author, to seek ways to produce a stronger and more influential voice for inclusion and transformation. Between 2002 and 2004, four influential collaboratives were created toward these ends.

Academic Consortium for Integrative Medicine and Health (“The Consortium”) The accomplishments of the Consortium, noted above, included: publishing “Competencies for Integrative Medicine” in Academic Medicine (Kligler et al. 2004); creating sample curricula; holding biennial NIH-backed conferences; and successfully requesting the leading accreditor of hospitals and medical delivery organizations, The Joint Commission, to reconsider its pain standard and more significantly include non-pharmacologic approaches (Weeks 2014).

Bravewell Collaborative Philanthropy plays a major role in all of US medicine and the same was true of the integrative movement. A set of these led by Penny George, the spouse of the former CEO and chair of Medtronic, and Christy Mack, the spouse of the former chair of Morgan Stanley, banded together to jointly invest in strategic projects to accelerated the movement. These projects included: the Consortium, a major public television documentary (The Bravewell Collaborative 2006), a Summit on Integrative Medicine and Health of the Public at the National Academy of Medicine (Institute of Medicine 2009), and multiple reports that highlighted the movement (The Bravewell Collaborative 2020).

Integrative Health Policy Consortium (IHPC) Federal elected officials who were friendly to the movement urged the different fields to come to Congress as one voice. As of 2019, IHPC had 27 partner organizations. The range was broad: integrative medical doctors; chiropractors; holistic nurses, naturopathic doctors; midwives; acupuncturists; homeopaths, and others. IHPC’s most significant work was that it had a hand in crafting 5 segments of the 2010 Affordable Care Act (Weeks 2020a). This historic level of inclusion related to delivery, workforce, payment, research and public health. It included the first recognition of the term “integrative health” in federal statute and an expansion of recognition of “complementary and alternative medicine” practitioners. What was once utterly outside federal law was gaining a presence within.

Academic Collaborative for Integrative Health (“The Collaborative”) The Collaborative aggregated the councils of colleges and other agencies for the licensed “CAM” fields (s. Table 1). Their accomplishments included: production of the interprofessional resource referenced above, the Clinicians and Educators Desk Reference on the Integrative Health And Medicine Professions; taking the lead in a National Education Dialogue to Advance Integrated Care: Creating Common Ground (Weeks et al. 2005) to engage with members of the Consortium; and participating in the movement for interprofessional education and team-based practice. Their most notable work has been in representing the integrative health field in the Global Forum on Innovation in Health Professional Education at the National Academy of Medicine. There, they provided leadership nationally in bringing forward subjects related to shifting focus toward health and well-being.

Two other important organizations were formed roughly a decade later. Integrative Medicine for the Underserved focused on the lack of equity and access to the predominantly cash-funded integrative services among populations that did not have such excess capital. The Academy of Integrative Health and Medicine was created by holistic and integrative medical doctors who invited in their colleagues in the licensed integrative health fields to start the first, inclusive interprofessional professional organization. By 2014, leadership of these organizations were on working terms with each other and were coordinating efforts in multiple areas.

3.2.5 Era 5: Convergence in Health Creation (2010–)

The Obama-era Affordable Care Act of 2010 marked the formal arrival of the volume-to-value movement in US medicine. Leaders of academic Integrative Medicine organizations agreed in a 2013 survey that value-based care was creating an environment in which they were perceived to have more value to their larger delivery organizations (Weeks et al. 2016). More specialty groups were exploring how the integrative model might assist them in achieving their needs. A subset of those surveyed saw increased investment of their integrative efforts from the parent organization. Over 88% of these leaders of clinical centers among the Consortium perceived that they were operating with stronger values alignment in the era of accountable care. This sense of alignment was affirmed by the CEO of a major health system in a presentation sponsored by the Bravewell Collaborative:

“When I first heard of integrative medicine in 2006, I thought of it as an expense. But as the Affordable Care Act’s payment structure kicks in that supports keeping people healthy, integrative medicine will be an asset.” (Paulus 2011)

The integrative movement was more prepared than ever. Evidence of cost savings began to emerge. The Collaborative gathered most of this evidence on their website (https://integrativehealth.org/reducepercapitacost). A first thorough examination of cost-effectiveness in complementary and Integrative Medicine led by Patricia Herman, ND, PhD found evidence of significant cost-effectiveness in 28 separate studies (Herman et al. 2012). A close examination of 4,200 patients at the Benson-Henry Institute at Harvard Medical School who had completed a multi-week mind body program found wildly confirmatory evidence. As compared with matched pairs, the completers averaged 42 percent lower use of conventional services (Stahl et al. 2015). The findings, which held across emergency room visits, prescriptions, physician visits, and hospitalizations, provoked the authors to declare that evidence based mind body programs should potentially be spread to the whole public with the same governmental backing as vaccines and drivers education.

This commences a truly integrative era in which certain complementary and integrative services were being explored as ways not just to lure patient but to meet declared values. In the United States, convergence in action began first in two areas: oncology and treatment of people with chronic pain. In the former, the Society for Integrative Oncology (SIO) had fostered, in the competitive oncology marketplace, expanding interest in complementary services. Integrative oncology began to be the norm rather than the exception in major oncology centers. Concurrent with the uptake, SIO, under the leadership of past-presidents Heather Greenlee, ND, PhD and Suzie Zick, ND, MPH, engaged an ongoing process of guideline development. It culminated in the influential American Society of Clinical Oncology endorsing a guideline for integrative practices in the treatment of patients with breast cancer (Lyman et al. 2018).

The second, broader, and potentially much more influential evidence of the arrival of complementary and integrative practices and practitioners was stimulated by the nation’s crisis in the treatment of people with chronic pain. This whole systems issue reached headlines and policy attention reductively as the nation’s “opioid crisis.” The challenges were first felt in the military, where problems of returning soldiers and veterans produced the first robust exploration of non-pharmacologic, integrative interventions (Jonas et al. 2010). Key research was provided over the period of a decade through the Samueli Institute led by the first influential director of the NIH Office of Alternative Medicine, Wayne Jonas, MD. A former US Army Surgeon General Eric Schoomaker, MD, PhD became an outspoken advocate for the integrative model. A survey of CAM use reported in 2017 found that of the 142 military treatment facilities in the military health system, 110 (83%) of the 133 respondent facilities offer at least one type of CAM and 5 more plan to offer CAM services in the future (Madsen et al. 2017).

The interest in the government health care systems of the military and the sprawling Veteran’s Administration (VA) led to the most remarkable leadership of the Integrative Medicine professionals in shaping US medicine. The founding director in 2011 of the VA Office of Patient Centered Care and Cultural Transformation, Tracy Gaudet, MD, and her successor in that position in 2019, Ben Kligler, MD, MPH, were each long-time leaders of the Integrative Medicine movement. Gaudet had directed programs at what is not the University of Arizona Andrew Weil Center for Integrative Medicine and Duke Medical School for 15 years. Kligler’s experience included chairing the Consortium and directing data-gathering in a Bravewell-funded network of integrative academic medicine clinical programs.

Together, these two and their team envisioned and built the VA’s Whole Health program that featured expansive use of integrative services including chiropractic, acupuncture, massage, Mind Body Medicine, yoga therapy, tai chi and others. The program, which conceptually placed the veteran and his or her family at the center of care (Weeks 2018b), was piloted and thoroughly researched in 17 of the VA’s medical centers. A broad array of positive outcomes (Bokhour et al. 2020) led the VA, three years later, to expand the program to 55 medical centers. Notably, this action was taken in the context not of the competitive, volume-based industry but in the single payer VA system. There, like in the United Kingdom, practitioners were employed. In the VA hierarchy, they could also be required to learn about integrative practices and practitioners. These cultural-economic traits of the VA operation supported the most intensive integrative environments in the US.

Yet in the world of civilian medicine, convergence was also evident. Other forms of integrative activity also accelerated. Research related to complementary practice and practitioners funded by the military and by the NIH created a body of evidence that, with policy nudging, began to shift the chronic pain dialogue. Members of the Consortium, as noted above, convinced a key accrediting body to engage a review process that casting a spotlight on the value of non-pharmacologic approaches such as acupuncture, massage, chiropractic and mind body approaches in pain treatment (Division of Healthcare Improvement 2018). Within a half-decade, the American College of Physicians (Qaseem et al. 2017), and the National Academy of Medicine (Bain et al. 2019) were among the organizations and agencies that had either issued guidelines or guidance documents that stressed the importance of integrating these non-pharmacologic, integrative approaches.