Toward Integrative Health National Acupuncture Detox Association Austin Texas March 22 2019 John Weeks PublisherEditor Integrator Blog News amp Reports EditorinChief JACM Paradigm Practice and Policy Advancing Integrative Health ID: 810591
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Slide1
NADA Amidst the 50-year Evolution Toward Integrative Health
National Acupuncture Detox AssociationAustin, Texas – March 22, 2019
John WeeksPublisher-Editor, Integrator Blog News & ReportsEditor-in-Chief, JACM – Paradigm, Practice and Policy Advancing Integrative Health (The Journal of Alternative and Complementary Medicine)Columnist: Today’s PractitionerColumnist: Integrative Medicine-A Clinician’s JournalBlogger: Academy of Integrative Health and Medicinewww.johnweeks-integrator.com
Slide2OverviewCliff’s Notes History
5 Eras for IHMDominant school: shadow history ConvergenceStrategies
CreditsDisclosure: I have no conflicts of interest. I do have multiple alignments of interest, including as JACM editor-in-chief, and volunteer roles with multiple not-for-profit IHM organizations.
Ruth Westreich Southern California University of Health Sciences Chief Philanthropic Partners
Jeana Kimball, RDHs, ND, LM, MPH
Chief Co-Conspirator
Bill Wulsin, ND, MA, MPH, LAc
Some threads – acupuncture, group-delivered services, mindfulness, relationship
Slide3Interested in the History?
“History is written by the victors.”
Walter Benjamin1892-1940
“Those who cannot remember the past are condemned to repeat it.”
George Santayana
1863-1952
5 Eras in the History of IHM – Webinar for Duke Leadership Program in Integrative Medicine
June 14, 2018
Slides from 2015 J Weeks AIHM talk - “A Winner’s History for IHM
”
http://functionalforum.com/wp-content/uploads/2015/11/AIHM-J-Weeks-Plenary-102515.pdf
Podcast interview on the history with James Maskell/Evolution of Medicine: December 16, 2016
http://goevomed.libsyn.com/webpage/page/7/size/10
The Rise of Integrative Health and Medicine: 120 Milestones 1963-present (Sabin, Walsh, Weeks)
https://fonconsulting.com/resources/the-rise/
Slide4A chosen framing for our history
Slide5Cliff Notes IHM History: 5 Eras
Slide6Pre-History: The Way We Weren’t“The Best Medicine in the World”
Oops, sort of missed …
Authoritarianism/abuseMen’s clubSurgeon’s clubPrimary care failureInterprofessional failureMono-culturalism/N EuropeMono-racialReductive perspectiveFocus on productionHigh costs, poor outcomes
Slide7Era #1: Origins in Affirming New Waysa.k.a. “Counterculture”-1965-1978
We Shall Overcome, some day
Adele Davis:
Eat Right for Your Health
Back to the Land:
Re-Connecting to Natural Process
Opening to the East, Globalism
Herbs can be powerful agents
Rachel Carson:
A Silent Spring
Women’s movement ”take back our bodies”
Slide8Disclosure
Slide9Lincoln Detox
Mutulu ShakurLincoln Detox Acupuncturist; Co-founder, Black Acupuncture Advisory Assn. of North America
Thanks to Robert Lederer’s 2014 Master’s Paper: “An Exploratory Study of New York City Community Acupuncture Clinics Serving Low-Income Communities”1970-1978November 10, 1970“Using surprise as the main tactic, we took over the residents’ auditorium and announced that we had decided to run a drug detoxification program right there. Thus the Lincoln Detox Program was born. Before the astonished eyes of many personnel, we began organizing the space and setting up as casually as someone might change the furniture at home
.”
Young Lord leader Mickey Melendez
Michael
Smith
Lincoln Detox Medical Doctor and Acupuncturist;
NADA Founder
Slide10James Reston: N of (a Very Influential) 1
New York Times
Reporter James Reston (1971):For the acupuncture field, a timely appendicitis
Slide11Beginning of patient-centered care movement: Founded 1979
Founded
1981
Founded 1978
Naturopathic Medicine Resurgence:
John Bastyr College of NM (Seattle)
Canadian College of NM (ON)
Founded 1978
Founded: 1979
Founded 1977
Founded: 1982
Founded: 1983
Founded 1973
Era #2:
Advancing in Silos
1978-1995
Slide12Early Mindfulness/Mind-Body Research
1977: Herbert Benson, MD - The Relaxation Response1977: Kenneth Pelletier, PhD, MD (hc) – Mind as Healer, Mind as Slayer
1979: Jon Kabat Zinn, PhD – The Stress Reduction Program (MBSR)
Slide13Medical Exchange with China:
Harvard’s David Eisenberg, MD (1979)Under National Academy of Sciences auspices
First medical exchange student to the People’s Republic of China (1979)Ted Kaptchuk, OMDEisenberg’s Harvard collaborator & author:The Web That Has No Weaver
Slide14Incorporated 1985
Slide15Action in Silos: Getting One’s House in Order to Create Standing
*Only schools accredited via the Commission on Massage Therapy Accreditation. There are over 1300 schools.Source: Clinicians and Educators Desk Reference on the Licensed Complementary and Alternative Healthcare Professions. ACCAHC. Goldblatt, Weeks, Rosenthal et al. 3rd
Edition, 2017.ProfessionAccrediting Agency EstablishedUS Department of EducationRecognitionRecognizedSchools or ProgramsStandardized National ExamCreatedStateRegulation*
Licensed
Practitioners
Acupuncture & Oriental
Medicine
1982
1990
60+-
1982
48
35,000
Chiropractic
1971
19741519635075,000Massage Therapy1982
2002
75*
1994
44
280,000
Direct-Entry Midwifery
1990s
2001
10
1994
26
2000
Naturopathic
Medicine
1978
1987
8
1986
16
7500
Slide161993 Turning Point for Integrative Health & Medicine:Survey of Consumer Use (Not a Trial or Review)
Unconventional Medicine in the United States (1991 survey data)Eisenberg, et al New England Journal of Medicine, January 28, 1993
Academic center for research team; David Eisenberg, MD, Lead Author34% of the population had used some “unconventional” treatment$13.8 billion spent, mainly out-of-pocketLittle communication with conventional providers____________________________Impact was transformative:Market interest from hospitals, insurers, media, political figuresIndividual activists empowered:
I am not alone
Publication revealed breadth of the popular movement
Slide17Era #3: “Non-Integrated Integration”1995 –
still working on this
Delivery: Stand-alone health system-sponsored “integrative medicine clinic”Payment: Insurance coverage for “CAM” but not in the core benefit
Slide182 Big Lessons (Non)
Slide19Perverse Incentives in Insurance: The 80/20 Rule
If you are running the insurance corporation, what does your self-interest favor?
Slide20Perverse Incentives in Delivery: The Tendencies of a Production Orientation
It doesn’t mean that production drives everything …
If a CFO targets X angioplasties, what is a successful year?What is the attraction of an Ornish program when you have a huge heart center?30% of what we do is waste, and much of it harmful (IOM)
Slide21Challenge of “Perverse Incentives”
“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”
Upton Sinclair1876-1968
Slide22Yet Some Good Signs …
Slide23Relationship Based Medicine
Practitioner-PatientPractitioner-PractitionerPractitioner-Community
Fetzer FoundationPew Center on Health Professions1994
Slide24Congressional NCCIH Appropriations - Federal Budget
(more CA /IM in other NIH institutes)
YearMillions1992$2.01998$19.5
1999 (NCCAM)
$50
2005
$123
2013
$120
2017 (NCCIH)
$130.5
2019
$145
Slide25Founding of SAR – 1992/93
Hannah Bradford, LAcStephen Birch, LAc
Patricia
Culliton, LAc
Slide26First Major “CAM” NIH Grants – with ND and LAc PIs!
Bastyr College: AIDS/HIVLeanna Standish, PhD, ND, LAc
Hennepin Faculty Assoc: Acu-Pain Patricia Culliton, MA, LAc_________________How? Former National College of Naturopathic Medicine student was acting director of the NIH OAM:Alan Trachtenberg, MD, MPH
Slide27First Peer-Reviewed (soon to be indexed)
Journals in the Field 1995-1996
Slide28Huge Federal EBM Steps for Acupuncture
1995: FDA approves needles as devices
1997: NIH Consensus Conference
Slide29Acupuncture EfficacyA Compendium of Controlled Clinical Trials (August 1996)
Sponsor: National Academy of Acupuncture and Oriental Medicine
Authors: Stephen Birch, LAc & Richard Hammerschlag, PhDTiming: Just after FDA action
Slide30An Encounter with Michael Smith:
AHA “CAM in Hospitals” Conference, January 2001
“If you want to empower patients, just put more patients than providers in the room.”
Slide312001: now 27 Partners for Health
2001: now 70+ academic health centers and delivery orgs
2004: now Multidisciplinary, 17 national organizations plus 40 schools
2001: Philanthropists: numerous important strategic investments
Era #4:
Advancing in Collaboration
2001 - present
Two Interprofessional “Big Tents”
2009: 6 physician level IHM organizations
Slide32IHPC Partners for Health
Slide33“The Consortium”
Organizational GrowthFrom 8 to 72+Key Publications
Definition of IMCompetencies in IMMajor Research Conferences2006, 2009, 2012, 2014, 2016, 2018 – with NIH backingMajor Philanthropic PartnershipBravewell Collaborative
Slide34Integrative medicine and health reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches,
healthcare professionals and disciplines to achieve optimal health and healing.Relationship-Oriented & Interprofessional
Definition of Integrative Medicine and Health
Slide35Cliff Notes: Shadow History of the Dominant School
Slide361999: IOM’s To Err is Human Est. 100,000 deaths/year due to medical errors
2001: IOM’s Crossing the Quality Chasm
BMJ 2016: Est. 251,000 medical deaths a yearOut of the Shadows: Medical Deathshttps://www.bmj.com/content/353/bmj.i2139
Slide37https://www.huffingtonpost.com/entry/chronicle-of-health-creation-the-shadow-in-berwicks-call-for-a-moral-era-for-medicine_b_9396516.html
Slide38Era #5: Convergence - 2011 to present
Slide39“Value-Based Medicine”
Interprofessionalism/team care
Shifting Payment Incentives
Quadruple Aim:
Value-Based Medicine
Personalized “Precision” Medicine
Patient-Centered Care
Focus on Healthy Communities
and Health Creation: Whole Systems
Slide40VBM: Countering Stress, Burnout
Slide41From “Sick Care” to “Creation of Health” – How-to Questions
Berwick (2013): “ … the new way, the way to health, may be vastly further from the current design of care than we may at first wish it to be, or believe it to be …The pursuit of health, the creation of health, may require something even bolder [than the Triple Aim].
The redesign we need may be even more radical than we have imagined."AHA’s Perlin (2013): “We have been honed to focus on sick care … It is a tough transition, but we have to learn how to move from sick care to health care. I'm not sure that any of us fully understands or knows the recipe."Jonathan Perlin, MD, PhDPast Chair, AHADonald Berwick, MDFormer CMS Administrator
Slide42Whole Systems Research
Values-Based Medicine
IndividualizationPersonalized/patientHealing/health outcomesResilience, well-beingTeam careInterprofessionalismMulti-modalLifestyle/chronic diseaseGrowing Values Alignment
Slide43Integrative Leadership of Health Care - 2018
Integrative
healthv health leaders are mentoring the most significant influencer of reform in US medicine
Berwick: “My mentors in salute-genesis … “
https://www.huffingtonpost.com/john-weeks/don-berwick-integrative-m_b_4781105.html
Private Not for Profit Medicine
Government Medicine/VA
“You are the center of mass for the ignition of the transformation of health care in this country.”
Former US Army Surgeon General Eric Schoomaker, MD, PhD, ICIMH, May 9, 2018
Slide44Multimodal Approaches in Integrative Health:
Whole Persons, Whole Practices, Whole Systems
https://www.liebertpub.com/toc/acm/25/S1
Slide45Global Alignment, Briefly …
Slide46WHO-PAHO Traditional Complementary and Integrative Medicine StrategyWHO’s strategy promotes use of traditional medicine “products, practices and practitioners” to help meet goal of universal health care and primary care for all
http://mtci.bvsalud.org/en/
https://www.who.int/traditional-complementary-integrative-medicine/en/
Slide47But … How to Create Convergence in Access?
Slide48Eisenberg: IHM clientele, higher income, higher education, whiteBusiness models: With little insurance inclusion and model misfits, cash basedConcierge integrative/FM practices: Direct targeting of a wealthy clienteles
The Integrative/Functional Medicine Cash Practice Problem
Slide49From 1980s into 1990s: “CAM” academic institution partnerships with community clinics1995: First Government-funded natural medicine center (in an FQHC)Prompted by staffer for WA State Sen. Kent Pullen (R) staffer Merrilee
Manthee1997: HHS-sponsored workshop in complementary, alternative and traditional medicineYear: APHA begins special interest group, now Section on Integrative, Complementary And Traditional Health Practices
Embracing the IHM Access Issues
Slide50Mindfulness Models Ornish, Benson, Jon Kabat-Zinn programs all group basedStanford/Breast Cancer David Spiegel and support group intervention
HMO/Kaiser: Drop-In Group Medical Appointments (“DIGMAs”)Patient Centered Medical Home
Since 1990s: Gathering Streams for Group-Delivered Services
Slide51https://www.huffingtonpost.com/entry/chronicle-of-health-creation-the-shadow-in-berwicks-call-for-a-moral-era-for-medicine_b_9396516.html
Acupuncture Without BordersFounded 2005
Slide52Community Based Acupuncture & POCALisa Rohleder, LAc, Working Class Acupuncture, driving forceIntegrative Medicine Group Visits
PCORI grant to Paula Gardiner, MD, MPH
Gathering Streams for Group-Delivered Services
Slide53Integrative Medicine for the Underserved: Coverage of Group is a Top Policy Priority
www.im4us.org – Founded 2011
The other top is insurance/Medicaid/Medicare coverage of complementary and integrative practices and practitioners
Slide54Opioids and the Awakening to Non-Pharmacologic Approaches
CDC Guideline for Prescribing Opioids for Chronic Pain – March 2016
Slide55A New World for USA Pain Treatment:Non-Pharma in New 2016-2018 Pain Guidance
Some Examples of Non-Pharma LanguageJoint Commission
in a 2015 revision of its pain standard recommends multiple non-pharmacologic, integrative strategies including acupuncture, massage, chiropractic and relaxation therapies.Mayo Clinical Proceedings published an “Evidence-Based Evaluation of Complementary Health Approaches for Pain Management,” based only on research from the United States, offering scientific evidence for multiple integrative modalities and practices.American College of Physicians earlier this year updated its low back pain guideline, recommending that “physicians and patients initially select non-drug therapy with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise (MCE), progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.” National Academy of Medicine in a report last month for the FDA, concluded that “nonpharmacologic interventions for pain treatment, including acupuncture, physical therapy and exercise, CBT, and mindfulness meditation, represent powerful tools in the management of chronic pain. Many are components of successful self-management.” Association of States Attorneys General urged insurers to cover non-pharma: “When patients seek treatment for any of the myriad conditions that cause chronic pain, doctors should be encouraged to explore and prescribe effective non-opioid alternatives, ranging from non-opioid medications (such as NSAIDs) to physical therapy, acupuncture, massage, and chiropractic care.”
Slide56Practitioner-Policy: Sample State Pain Pilots
Oregon – multiple non-pharma, back & spine – Medicaidacupuncture, chiropractic, CBT, osteopathy, plus yoga, intensive rehabilitation, massage, and/or supervised exercise therapy https://www.integrativepractitioner.com/whats-new/all-news/oregon-approves-integrative-treatments-for-back-and-spine-conditions/
Vermont – Acupuncture, Back Pain - MedicaidAcupuncture pilothttps://www.integrativepractitioner.com/whats-new/all-news/vermont-funds-acupuncture-chronic-pain-medicaid-pilot-project/Washington – Acupuncture, Back Pain – Labor/IndustriesBack pain; gathering datahttps://www.integrativepractitioner.com/whats-new/washington-minnesota-initiate-acupuncture-interdisciplinary-pain-payment-trials/Ohio – Acupuncture, Back Pain, Migraines – MedicaidBack pain; gathering datahttps://www.integrativepractitioner.com/whats-new/all-news/ohio-open-medicaid-acupuncture-comment-period-open-june-23/Maine – NADA – substance abuse - Medicaid5 point ear protocolhttps://www.integrativepractitioner.com/whats-new/all-news/maine-to-begin-national-acupuncture-detox-association-pilot-project/John Singer, LAcRobert Davis, LAc, MSLaura Ocker, LAcKimberly Tippens, ND, MSAOM, MPH.
Jared West, LAc
Lisa Taylor-Swanson, EAMP, PhD, Jennifer Stone, LAc; Megan Gale, MSAOM,
DiplOM
, EAMP,
Mary Beth Hassett, LAc,
Dipl
OM
Slide57Slide58Chao/Adler: “Threefold strategy to advance health justice through the use of integrative medicine principles”
Leverage integrative medicine to advance health equity, that is, the attainment of the highest level of health for all people.
Promote an integrative medicine culture that upholds the values of diversity, equity, and inclusion.Address intrapersonal attitudes, beliefs, and behaviors that perpetuate bias and discriminationhttps://www.liebertpub.com/doi/abs/10.1089/acm.2017.29042.mtc
Slide59Results When Center Shifts Acupuncture to Group Model
Source: Society for Integrative Oncology conference, October 2018
http://www.johnweeks-integrator.com/uncategorized/group-visits-spotlight-acupuncture-access-income-up-at-integrative-center-call-for-papers/
Slide60Cleveland Clinic Center for Functional Medicine:
Group More Effective Than Individual Treatment
Based on Patient Reported Outcomes (PROMIS) ScoresIndividual: moved 30% of patients 5 “PROMIS points”Group: moved 40% of patients 5 PROMISE pointsIn early data, patients in Functioning for Life 10 week shared medical appointment” responded 30% better than those seeing practitioners one on one.Source: Mark Hyman, MD, Integrative Healthcare Symposium, Feb. 2019
Slide61Neighbors Treating Neighbors
http://www.johnweeks-integrator.com/uncategorized/wyomings-radical-openness-to-nada-ear-acupuncture-community-healing-model-for-anyone-with-the-blues/
Photos, top down: Rohleder, Working Class Acupuncture, Gardiner
Slide62An Opportunity to Elevate
“Innovation in Group Delivered Services”
Slide63Transformation
Slide64What Influences Health?
Slide65Medical Delivery Organizations as Anchor Institutions to Address Social Determinants
http://www.ihi.org/resources/Pages/AudioandVideo/Don-Berwick-Forum-Keynotes.aspxhttp://www.ihi.org/resources/Pages/AudioandVideo/Don-Berwick-Forum-Keynotes.aspx
Slide66Shifting the Perverse Incentives: What’s Next?
Integrative Medicine and Single Payer: What Might We Expect?http://www.johnweeks-integrator.com/uncategorized/integrative-practices-and-practitioners-and-single-payer-what-might-we-expect/
Slide67John Weeks
johnweeks-integrator.com
Publisher-Editor
The Integrator Blog News & Reports
johnweeks@theintegratorblog.com
Editor in Chief
JACM:
Paradigm, Practice and Policy Advancing Integrative Health
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