Summary: In 2005, Hawaii’s major Blue Cross Blue Shield carrier, HMSA, contracted with Manakai O Malama, the integrative clinic founded by Ira Zunin, MD, MPH, MBA on an unusual integrative, outpatient pilot for some of their most costly, pain-ridden, disabled members. The elaborate approach included diverse mind-body approaches, Feldenkrais and Yoga, and group acupuncture. Zunin, who was interested in a thorough biopsychosocial model, observes of the positive outcomes – reduced anxiety and depression, lower disability, reduced opiate use – that the ethical value in group process has both “carrot and stick” sides. Here is the pilot, with its outcomes.
Ira Zunin, MD, MPH, MBA offers a global, strategic perspective as to why he has made a priority of forming partnerships with insurers and employers to advance his integrative practice model for disabling pain: “We know we can spend a decade in the legislature trying to fight for one small thing. This is an opportunity to solve big problems which big payers know they have and create a lot of latitude for integrative medicine.”
Zunin’s base is his Manakai O Malama integrative center on the island of Oahu. Since it’s founding in 2002, the clinic has had over 100,000 patient visits to its array of practitioners. (See “Clinical Services” in the table). In 2005, the Zunin’s team partnered with Hawaii Medical Services Association (HMSA), the island’s Blue Cross Blue Shield carrier, and two workman’s compensation firms for an integrative pain pilot that targets a costly, disabled population .
“We viewed this as a chance to study a comprehensive biopsychosocial intervention,” states Zunin, an Integrator adviser.
“We viewed this as a chance to study a comprehensive biopsychosocial intervention,” states Zunin, an Integrator adviser. The program is family, community and group-based. Zunin adds that the approach particularly sought to “interrupt the pattern of social isolation” often found in such a population. Group process might shift the “pattern of suffering.” Working with families might increase positive secondary gains. The emphasis was on mind-body strategies which might reduce “pain-related depression that can contribute to suffering.”
Among the complementary and alternative
components included are the use of Feldenkrais and Yoga, humor, acupuncture in a
group-delivery model, and diverse mind-body therapies including a
program with elements of the mind-body stress reduction programs
developed by Jon Kabat-Zinn, PhD.
Intensive Outpatient Pain Program
|Program Sponsor||Manakai O Malama Integrative Healthcare|
at Manakai O Malama
|Pain management, preventive medicine,
primary care, occupational medicine,
family medicine, osteopathy, psychology,
acupuncture/Traditional Chinese medicine,
|Partner||– HMSA (Hawaii Medical Services Assn.
– 2 worker’s compensation carriers
|33 (in 5 cohorts)|
|Key services in the Integrative
Outpatient Pain Program
|Medical management, psychotherapy, pain
education, self-management techniques,
mind-body (meditation/Ho’o pono pono),
therapeutic Yoga and/or Feldenkrais,
family education & support
|Program elements||– Intake/selection (intensive)
– Cohorts: started 10-12
|– Physician interview
– If passed, 1/2 day of testing
– Beck Depression Inventory, Symptom
Checklist, Pain Patient Profile, Quality
(2 per 3 hour shift)
|4 of the activities were “tracks”
– Psychology/group process
– Mind-body (breathing, mind-body stress
– Therapeutic movement (Feldenkrais, Yoga)
– Acupuncture (in a group room – all received
|Outcomes: Quality of Life||– Improvement on all subjective, quality
of life measures
– Especially strong with anxiety
|Outcomes: Use of Opiates||– 79% were on these medications to start
– 50% of those on opiates ended use
|Outcomes: Disability||– 64% were disabled, prior to study
– 85% of these returned to work
|Program Cost||– Paid per diem, plus screening,
approximately $10,000 per participant
– Covered care and pilot development
Outcomes: anxiety, disability, opiate use down
Zunin reports that “the outcomes have been great.” Among those found were:
- Quality of life Scores for the 33 who completed all of the 12 weeks improved on all standardized, subjective measures, with particular advances in diminishing anxiety.
- Disability Of the 64% who had been disabled or partially disabled in the prior 12 months, 85% returned to gainful activity or were cleared to work. 100% of those who returned to gainful activity were still “gainfully engaged” at one-year follow-up.
- Opiate use Of the 79% who had been under high level opiate analgesics during the 12 months prior, 97% had reductions in use of 25% or more, 81% of 50% or more and 50% had 100% reductions on high level opiate use. At one year follow-up, 100% of those who substantially-reduced opiates remained off of them.
Zunin, reports that these positive outcomes have led to a discussions
with HMSA to make the program a covered benefit, and with the Veteran’s
Administration about expanding the program and offering it to vets.
The carrot and stick values of the group intervention
Zunin believes that the group-method of service delivery was a significant factor in achieving these positive outcomes. “The thing about pain and extreme obesity is that they are socially isolating. So, on one side” – what Zunin called the “carrot” – “you are interrupting this pattern.” He adds that he felt that acupuncture in a group model can particularly help: “There is something energetic that occurs as a group.”
Then Zunin explains how he believes that group-focused treatment also has a “stick” dimension to it. Reflects Zunin: “The other side of the group ethic is the stick. In this population, you typically have people who have learned to manipulate one provider after another. They spot that manipulation in each other and whomp each other for it when it comes up.” In short, the counseling from a fellow-patient may be much more direct and to the point than that from the patient’s doctor.
Zunin described plans for modifying the program from lessons learned in this round. First, Zunin anticipates screening all participants at the first 4 weeks. This would give a chance to “graduate” some of the quick responders and to remove some from the program who are clearly not engaged. In both cases, costs would be saved. Zunin also anticipates producing the three 4-week sessions as “chapters” with more of a thematic continuity.
Zunin, who founded the Hawaii State Consortium for Integrative Health Care, continues to believe that pilots such as this, which analyze outcomes of whole systems of care, in partnership with insurers or other payers is the way to transform the system. Says Zunin: “The contribution I would like to see to our shared field is to lighten the path to rapid change.”
For another article on Zunin’s work, please see (Zunin on CAM-IM Clinical Services in Healthy Living “Age Targeted” Communities, April 24, 2006).
Comment: Zunin’s comments about the value of the group reminded me of the astonishingly positive outcomes of the group-focused programs delivered to Chrysler employees onsite (Chrysler Expands Group-Focused Integrative Pain Partnership with Henry Ford Health System CAM Group, July 23, 2007; and Chrysler’s Health Leaders on Their Integrative Health Pilot Projects, February 26, 2008). Zunin agreed that there may be something in the individualized nature of the experience of pain which makes it particularly susceptible to group mind-body interventions.
To the extent that this may be true, our health professional educational programs must begin to train professionals to participate in and help lead these group interventions. The training in delivering such programs is essentially, as the fundamental, economic law of clinical decision-making seems to be that practitioners of all stripes are most likely to recommend services that they, themselves are equipped to provide.
Kudos to Zunin for having the vision to put this together and see it through this round. I agree with his strategic sense that these kinds of projects are the best way to light the path to quicker uptake of integrative practices.
for inclusion in a future Your Comments Forum.