Linda L. Bedell-Logan
President/CEO
Solutions in Integrative Medicine

Written Testimony for the House of Representatives
Committee on Government Reform

Oversight of the Department of Health and Human Services

The Role of Complementary and Alternative Medicine in the
Detection and Treatment of Women’s Cancers

A Perspective on Access to Integrative Medicine, Insurance Reimbursement and the Barriers in our Current Healthcare System

In 1987 my 25-year-old sister was diagnosed with a Ewing’s Sarcoma in the calf of her right leg. The protocol for Ewing’s is amputation, chemotherapy, and radiation in that order. This is a very aggressive cancer but thankfully it was caught early enough for treatment. I remember clearly my sister’s fear of losing her leg, mortified at the prospect of disfigurement at such a young age.

I was with her at a hospital in Florida during her treatment and remember when the oncologist came into the room and told us there was a new experimental treatment for Ewing’s that he would like to try. The doctor said the procedure involved inserting a tube into a vein near her groin and snaking the tube down her leg to drop chemotherapy directly on the tumor. He told my sister that this would not diminish her likelihood of survival but might well save her leg. On the strength of this hope, my sister opted for the new therapy.

At the beginning of the fourth treatment, the technician could not get the tube to slide into the same path they had been using previously. Somehow the vein seemed obstructed and my sister experienced intense pain. The technician gave up, and the next day they sent her to get a sonogram. The sonogram revealed a grapefruit sized tumor in the very spot they had been using to access her vein. Due to the size of the mass they could not operate. Then because of decreased lymphatic circulation, she developed massive bilateral lymphedema—a painful and debilitating swelling of the limbs. This caused her such intense pain the surgeons made incisions in her legs to "drain the lymphatic fluid". We now know that cutting into a patient with lymphedema is one of the worst things you can do. They put permanent drains in her thighs and both of the points of entry became severely infected. She became wheelchair bound and experienced excruciating pain 24 hours a day. They put her on high dose morphine and antibiotics to control the pain and infection, and we watched her die a slow, horrible death. She was diagnosed in June and died in late January.

After her death we found out my sister had been a guinea pig. The hospital had never performed this procedure before and the physicians hadn’t been trained to use it. It had never been tested and is not standard treatment protocol even today. I came away from this experience determined to bring more humane approaches into our supposedly state-of-the-art health care system.

One month after my sister’s death I started working for Medicare. My goal was to get down in the trenches and learn how the health care system in this country worked. I received an excellent education for three years at Medicare and then went to work for a large family medical practice. So I’ve seen the system work from all sides—patient, payer, and provider.

I opened Solutions in Integrative Medicine ten years ago. My company provides billing and practice management, consulting, and educational services for alternative and integrative medicine providers. Integrative medicine refers to a well-coordinated combination of traditional Western medicine and well-founded alternative therapies. At our company we have been in the forefront of change, actively advocating for patients whose insurance companies deny payment for effective but non-traditional services. We have been instrumental in developing the administrative and clinical basis for the coverage of a host of effective integrative therapies—often at greatly reduced cost. But this effort has been very tedious which makes it difficult to make a large enough impact for global change.

The US Public Health Service estimates that 70% of the current health care budget is spent on the treatment of approximately 33 million chronically ill individuals. As the population ages, such conditions will consume an even larger proportion of the national health care dollar. With this in mind my company’s vision is to change the perspective of the health care industry by providing professional education to insurance carriers, Medicare, physicians and patient consumers.

One of these chronic illnesses is lymphedema, something I witnessed during my sister’s ordeal. The principal cause of lymphedema is axillary lymph node dissection—a procedure performed both diagnostically and as part of radical surgery for breast and prostate cancers. Roughly 20% of breast cancer survivors suffer from this malady. There are three major consequences of lymphedema: swelling, recurrent infections, and tumor formation. Lymphedema patients who do not receive early intervention may develop elephantiasis, which can lead to amputation of the limb. Prompt treatment by specially trained lymphedema therapists who manually drain the engorged tissue has been shown to save limbs, save lives, and save health care dollars. This therapy is called combined decongestive therapy. It has been standard treatment in Europe for decades. But today it is considered an "experimental therapy" and is not typically a covered benefit. In the United States, our standard approach is to use expensive pumps that mechanically compress and decompress the affected limb even though this therapy has been shown to have little benefit. In fact it can press lymphatic fluid in the wrong direction and lead to a worsening of symptoms. For this reason, mechanical pumps for lymphedema have actually been banned in some European countries.

In the past two years we have been able to begin educating the insurance industry about combined decongestive therapy. We have been able to obtain coverage for Medicare patients in Maine, New Hampshire, Vermont, Massachusetts and Florida as well as many commercial insurance beneficiaries all over the country. This type of education and subsequent coverage has saved Medicare alone tens of thousands of dollars in Durable Medical Equipment supplies and has lowered the hospitalization rate significantly. Due in part to this work, Senator Kennedy sponsored HR 4328, The Women’s Health and Cancer Rights Act of 1998, which mandated coverage for lymphedema treatment. Even with this law in place, we are still struggling to obtain coverage for this treatment nationwide. Those patients who do receive this treatment are often those with the disposable income to afford it. The rest of the public receives conventional treatment, costing insurance companies millions of dollars each year.

The treatment of lymphedema is just an example of the education and common sense needed in the insurance industry. The illusion is that best medical practices are based on the results of randomized control trials. In fact it was recently estimated that only 15% of medicine today has been subjected to randomized controlled trials. It is a sad fact that since there is little to be gained by drug or medical equipment companies from the lymphedema treatment regimen I described, little attention or marketing money is focused on such common sense therapies. This is why health care cannot be simply left to the private sector. Too often the perverse incentives of our system lead to short-term thinking and pharmaceutical Band-Aids rather than comprehensive chronic disease management. The result, strangely, is poor quality care at higher cost. And those who can break out of this broken system are only those who can afford to pay out of pocket.

If we do not start moving back toward an outcomes-based, patient-centered, comprehensive care approach to chronic disease management, budgets will be busted, services will be slashed further, and the health, productivity, and competitiveness of our nation will suffer. It is time to heal the business of healing. We have an opportunity to meet patient demand and honor patient choice. Combining well-tested alternative therapies with the best of traditional Western medicine has been shown to improve health and reduce costs. We can have a system that works for patients, health care providers, and insurers. This is a tremendous win-win opportunity. But you cannot count on the private sector alone to take the lead. Health care is a highly regulated industry. We need leadership from government to allow this humane and common sense approach to prosper. With your help we can evolve a health care system that improves the quality of life and death for our citizens without the artificial constraints that are compromising the integrity of our physicians, healers and citizens. We must put prevention of chronic illness in the hands of the patients, treatment of chronic disease in the hands of integrative medicine teams, and acute and traumatic episodes in the hands of conventional medical providers.

Evolving Integrative Medicine

The inability of conventional medicine to address chronic disease has created a shift in patient demand for medical services. Patients, on their own, have found that complementary and alternative medicine (CAM) addresses quality of life issues, provides means for long term care management, and more importantly, often allows for a decrease in pharmaceutical utilization. These fee-for-service modalities are usually paid for out of pocket by the patients. Even when faced with these additional costs, patients seek care outside of their conventional provider networks, thereby creating access to choices that tie into their own belief system(s). However, when patients pay out of pocket for CAM services they may or may not report receiving these services to their Primary Care Physician—thereby creating potentially dangerous disconnects in the continuum of their healthcare.

The concept of regarding the patient as the consumer is a relatively new concept in health care. Concurrently, the philosophy that patient choice may yield more positive outcomes is one that is becoming more widely embraced. Today’s healthcare environment is one in which patients/consumers are choosing alternative branches of medicine that are not regulated by insurance guidelines. In the face of this reality, insurers are endeavoring to meet patient demand for alternatives by exploring means of expanding coverage to include these additional modalities.

In the past six years the rise in patient demand for CAM modalities has been repeatedly validated. Two surveys conducted by David Eisenberg, MD and colleagues from Harvard Medical School (1993: NEJM 328:246-252; 1998: JAMA 280:1569-1575) have thoroughly documented the prevalence and trends of use for CAM modalities amongst the American populace. In 1997 Eisenberg et al. found that "…extrapolations [from the survey sample] to the US population suggest a 47.3% increase in total visits to [CAM providers], from 427 million in 1990 to 629 million in 1997…." In both survey years the number of visits to CAM providers exceeded "the total visits to all US primary care physicians." Eisenberg et al. conservatively estimated that total expenditures on CAM modalities in 1990 was "approximately $13.7 billion." The 1997 data indicates that "estimated expenditures for alternative medicine professional services increased 45.2% between 1990 and 1997 and were conservatively estimated at $21.2 billion in 1997, with at least $12.2 billion paid out-of-pocket. This exceeds the 1997 out-of-pocket expenditures for all US hospitalizations." Moreover, upon further analysis, we see that "total 1997 out-of-pocket expenditures related to alternative therapies were conservatively estimated at $27.0 billion, which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services.

Since 1998 more research dollars have been shifted toward CAM therapies with the establishment of the National Center for Complementary and Alternative Medicine (NCCAM). The Senate Appropriations Committee funded the NCCAM with $50 million to further the work begun under the auspices of the NIH Office of Alternative Medicine with its original budget of $2 million.

As more research results are published, it is affecting the way insurers are covering lives. As patient demand increases, insurers are creating ways to expand coverage to include some CAM therapies. The therapies insurers are attempting to include in benefits packages have little historical financial data (since they are primarily paid for out-of-pocket and not processed through a billing service). Actuaries are finding that insuring CAM therapies is a difficult challenge. Without historical data as a foundation for an insurance plan, coverage of CAM therapies can appear to be too speculative. What is most difficult to determine in these actuarial attempts at coverage planning is the concept that by utilizing CAM therapies a patient will utilize fewer conventional therapies. This concept is most easily demonstrated when investigating conventional approaches to chronic illness such as arthritis, allergies, pain, hypertension, cancer, depression, cardiovascular disease and digestive disorders. Patients who fall within these categories of diseases are under obligation to move through the insurance system as outlined in Chart 1. These types of diseases are becoming easier to diagnose with more documentation available outlining classic symptoms. For example, less testing will be needed to properly diagnose migraine headaches, chronic fatigue syndrome, and myofascial pain syndrome. However, this gradual decrease in the need for diagnostic testing does not address the quality of life issues and long term treatment costs.

The plan of care referred to in Chart 1 does not entitle the patient to options that may cost less and more directly address the patients’ chronic migraines. There are many CAM therapies available that have been found to relieve (without pharmaceuticals) and in some cases resolve migraine headaches. Hesitations preventing the use of CAM interventions at the onset of the complaint are concerns that life threatening problems will be overlooked due to lack of diagnostic testing.

The concept of integrating conventional and CAM therapies is one that embraces the diagnostic process at the primary care physician level to rule out serious illness. The U.S. Public Health Service estimates that nearly 33 million Americans suffer from chronic debilitating diseases. It is estimated that the medical care of 9 million of these individuals, who are partially or completely disabled, accounts for 70% of the spending in current health care budget. Most of the spending associated with patients who fall into this category occurs in the final stage of the process outlined in Chart 1. These patient issues are unresolved—therefore creating a revolving door of over-utilization of health services—which becomes more costly as the patient grows older. Appropriate CAM therapies introduced after appropriate diagnostic testing may significantly improve the quality of life for the patient as well as control the cost of future medical care.

The patient, in the Integrative setting will be educated about their illness, instructed in ways of coping with pain that do not involve pharmaceuticals, and be treated with an appropriate CAM modality that ties in with the patient’s belief system, thereby producing a more positive outcome. One of the less obvious benefits to this type of care plan is getting these types of patients off disability and back to work. Integrative medical approaches can also create a partnership based in prevention. CAM techniques encompass lifestyle changes that are significant to the course of prevention. This course is essential to building long term approaches to the prevention of the diseases that continue to drain health care dollars.

In an attempt to collect data many insurers have created rider policies or have become affiliated with pre-credentialed CAM provider networks. Rider policies usually cover an array of the CAM therapies most in demand. Many of these therapies carry strict utilization review guidelines that limit the number of visits or may have a monetary cap. Rider policies are purchased separately from a standard policy. Many employers are demanding policies that include CAM therapies due to a rise in absenteeism as well as employee complaints about lack of choices. Insurers, in an effort to comply with employer requests, will create a rider policy specific to that employer. CAM provider networks contract with some HMO plans. The plans will allow patient access to the providers at a discount to the patient. This option minimizes the risk to the insurer, and allows access to the CAM provider at a discount to the patient. The providers are usually credentialed and screened before entering the network.

Another issue that impairs the ability to implement comprehensive CAM coverage plans is credentialing. In an effort to reduce medical fraud and quackery, medical societies have developed strict licensure laws that govern the scope of practice of physicians and ancillary medical personnel within each state. Many CAM modalities, techniques and therapies are taught to a diverse group of medical providers. For example, craniosacral therapy classes are attended by nurses, doctors, massage therapists, physical therapists and others. Insurers are finding it difficult to credential a provider to perform craniosacral therapy when there is no licensure or certification in the delivery of this care. CAM provider networks across the United States are developing expertise in the credentialing of these providers. CAM provider networks provide credentialing criteria that parallel the teaching institutions most highly respected in their respective fields. The relationship between the insurer and the CAM network is essential to the quality of the care delivered in CAM medicine. Either of these interim coverage steps will allow and help to build a financial basis for the coverage of CAM. This in turn will create access for patients who cannot afford to pay out of pocket. However the CAM network is not a long term solution to patient access because of the lack of integration with conventional medicine.

Coding, Diagnosis and Procedures

Although the process of integration under one coding system has been a challenge, the American Medical Association has taken significant steps toward accepting CAM therapies such as physical therapy, osteopathy, chiropractic, acupuncture, manual therapies, and psychiatric services such as biofeedback and hypnosis. The AMA has adopted CPT codes for many CAM techniques, which in turn has opened doors to access and coverage for patients. The downfall of these conventional coding schemes, created for CAM interventions but conceived from an allopathic perspective, occurs when CAM providers attempt to implement them. CAM providers tend to see patients from a holistic point of view, but the coding schemes assume that human ailments are best described as organ-specific pathologies. How does one "code" the treatment of an intestinal ailment that a CAM provider perceives as related to emotional stress, nutritional deficiencies, lack of exercise and other lifestyle factors? Evaluation and management codes, in fact, specifically prevent holistic care from being performed. If an osteopath, for example, sees a need to do nutritional counseling and some manual adjustment he would not be able to do so under current guidelines. Comprehensive treatment of complex chronic illness almost always demands some significant educational component, but the thoughtful physician simply cannot find in the conventional code book the support needed to do this different kind of medicine. Other branches of medicine outside of the conventional medical education system, view a patient and their illness as one, and do not separate the disease from the patient.

The coding description states that "Evaluation and Management services may be reported separately if, and only if, the patient’s condition requires a significant separately identifiable E/M service, above and beyond the usual preservice and postservice work associated with the procedure". Many holistically-trained healthcare providers feel that a large part of the philosophical and educational basis of the medicine they deliver has been compromised with coding that focuses solely on disease and the efficacy of a modality. Physicians who cannot spend quality time with their patients, due to coding restrictions, often refer troubled patients to potentially expensive psychiatric care. Many of these psychiatric claims are denied due to lack of substantial psychiatric diagnosis. Physical therapists as well as chiropractors experience similar challenges. Physical therapy and chiropractic care come from a root of education that includes empowering the patients to better care for themselves. With a reimbursement system based on diagnosis, it is becoming increasingly difficult for CAM providers to care for patients as a whole, while also offering education and options for lifestyle change. Systems are in place that will allow a certain number of visits per year, per patient for a given diagnosis. CAM providers believe that each patient is an individual and will respond differently to any given treatment. With this diagnosis-driven reimbursement system patients have few choices in regard to their health care delivery. CAM psychiatric providers experience a similar problem when a patient presents with chronic pain. These CAM psychiatric providers submit claims to an insurance intermediary in many cases that has expertise in the utilization review of psychiatric claims. If the diagnosis is low back pain, for example, the claim is denied due to lack of "psychiatric diagnosis". However, the provider may change the diagnosis to "adjustment disorder" (may tie in as an inability to tolerate pain) and the claim will be paid. Many of these CAM psychiatric interventions also include manual therapy and self care training which may be referred to as a mind-body program. When the provider submits the claim for the manual therapy part of the treatment to the psychiatric claims intermediary, the claim is denied for two reasons. The first reason is that the procedure codes used to describe the manual therapy cannot be paid for with a diagnosis of adjustment disorder. The second reason is that this intermediary only pays for psychiatric procedures. The provider then changes the diagnosis to read low back pain and sends the claim to the medical policy division. Many times these claims are also returned to the provider denied as the patient has exhausted their physical therapy benefit for the year. It is customary to use physical medicine codes to describe all types of manual therapy services, not just physical therapy. However, many insurance carriers do not take into consideration the fact that many other types of providers utilize these codes. When the insurer sets a protocol for the number of visits per year by a physical therapist, they attach the guidelines to the procedure codes and the diagnosis codes. Even though the care has a different root of medical origin, these two fields utilize the same procedure codes and are adversely affected by insurance company processing systems that are unable to process claims based on usage by profession. Usage by profession would yield a quality of delivery that would permit integrative medicine to be incorporated into the existing reimbursement system.

In the absence of appropriate AMA approved CPT codes for some CAM therapies, more progressive insurers have created in-house procedure codes in an attempt to meet patient demands for coverage. Many CAM techniques can be described accurately with existing CPT codes, however many of these codes are used in the conventional setting with a different root of delivery. A dilemma that plagues this integration process occurs when existing CPT codes are used to describe CAM therapies, and the root of delivery is not housed in the same reimbursement assessment as conventional therapies. For example, a conventional reimbursement assessment may find it appropriate for a provider to spend 20 minutes with a chronic low back pain patient. Reimbursement for this service is calculated by the severity of the diagnosis. In naturopathic medicine a physician may spend 60 - 90 minutes with a chronic low back patient, which is appropriate based on the root of naturopathic medicine. The conflict occurs when the visit by the naturopath is reduced or denied because the guidelines for reimbursement are based in the root of conventional medicine, which is diagnosis-driven. The challenge for CAM providers is in educating the insurers in order to avoid fraud and abuse issues but also to protect the integrity of CAM approaches, given that the success of these therapies is intrinsic to how the care is delivered. The challenge for the insurer is to develop a reimbursement structure that will allow each profession to utilize the CPT codes currently available and create utilization review guidelines that are based on any given professions root of delivery. In the meantime, it is essential when coding CAM therapies using the CPT tool, that providers are in open dialogue with insurers in an effort to avoid fraud and abuse claims. For example, the appropriateness of utilizing evaluation and management codes to describe homeopathic assessments, even when performed by a MD, are seriously questioned at this time.

Many integrative centers have evolved across the United States. These centers usually include a medical director, usually a physician (MD, DO, or DC), with a staff comprised of such professionals as a naturopathic physician, an acupuncturist, a massage therapist, a nutritionist and a stress reduction program that incorporates lifestyle counseling such as the Jon Kabat-Zinn program, the Herbert Benson program, or the Dean Ornish program.

These professionals that are not easily credentialed by insurers are able to provide services under the direct supervision of the physician. The physician assumes responsibility for the therapists and bills "incident to" the physician. Incident to Guidelines for Medicare have very specific language addressing the employment relationship that is needed between the physician and other professional in order to deem incident to billing appropriate.

The education that is taking place in the insurance industry will continue to bring more and more players to the table to create an infrastructure that will introduce CAM to mainstream medicine. In a effort to reduce the cost of health care, more insurers will be allowing reimbursement for modalities that address chronic pain and illness. This in turn will reduce the over-utilization of services by patients who suffer from illnesses that conventional medicine cannot address in many cases without utilizing expensive and invasive interventions and/or pharmaceuticals.