Reference Guide: Language/Sections on CAM and Integrative Practice in HR 3590-Healthcare Overhaul

Summary: This article is meant as a reference resource on integrative practice and healthcare policy. Included are locations and exact language in the sections of the Patient Protection and Affordable Healthcare Act (HR 3590) that will shape policy action relative to integrative practices in coming years. Complementary and alternative medicine practitioners and integrative practices are included in these sections (2706, 3502, 4001, 4206, 5101, 6301 and 2301) relative to non-discrimination, workforce planning, community medical homes, wellness, prevention and health promotion, comparative effectiveness research and birthing services. Here are the facts, without interpretation or commentary. (If there are others, let me know.) What they will mean is up to us. The challenge ahead is to bring what one integrative practice lobbyist called “these major steps toward recognition” to life.

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HR 3590: “Major steps toward recognition” of integrative practitioners and integrative practices

Purposes

This document was created for two purposes. First, it is meant as a guide for anyone who wonders what exactly is the language of inclusion relative to integrative practices in the Patient Protection and Affordable Healthcare Act
(HR 3590), otherwise know as
healthcare overhaul legislation. Second, this compilation is meant as a useful reference document for all who are presently interest in federal policy and integrative practice. I have mostly kept my opinions out of it.

Meaning to the Integrative Practice Community: “Leveling the Playing Field”

A subset of the provisions noted here (2706, 3502, 5101) led one long-time lobbyist for an integrative practice profession to state the meaning this way:

“You have to put it all together. I don’t think you can sway that there is one single provision that levels the playing field. I don’t think the bill completely levels the playing field. But these are major steps forward and major steps toward the recognition of the profession. Of course, we have big plans to build on the these provisions. This is a significant start, it really is.” 

Those seeking commentary on the bill from a smorgasbord of 8 professional associations and natural products stakeholders will find links in the first article in this April 2010 Integrator Round-up (ACA, IHPC, AANP, APHA, NPA, MAMA, AAAOM, ANH). A thoughtful and hopeful editorial by Daniel Redwood, DC was recently published as Health Reform, Prevention and Health Promotion: Milestone Moment on a Long Journey.

To Go Directly to the Law

  1. Put http://thomas.loc.gov/ into your browser.
  2. Look on the right under “Weekly Top 5” and click on on H.R. 3590.
  3. Click onto Text of Legislation.
  4. Click into the 7th and final version of the bill. This will guide you section by section.

Here’s hoping this is useful.

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Patient Protection and Affordable Healthcare Act (HR
3590)

Sections Directly Related to CAM and Integrative Practices


Note: The bold lettering inside the law is added
to call out the specific language.


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US Senator Tom Harkin: Top advocate, key on this and other provisions

1. Inclusion of Licensed Practitioners Insurance Coverage

SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE.

(a) Providers- A group health plan and a health insurance
issuer offering group or individual health insurance coverage shall
not
discriminate with respect to participation under the plan or coverage
against any health care provider who is acting within the scope of
that
provider’s license or certification under applicable State law.
This
section shall not require that a group health plan or health insurance
issuer contract with any health care provider willing to abide by the
terms and conditions for participation established by the plan or
issuer. Nothing in this section shall be construed as preventing a
group
health plan, a health insurance issuer, or the Secretary from
establishing varying reimbursement rates based on quality or
performance
measures.

(b) Individuals- The provisions of section 1558 of the
Patient Protection and Affordable Care Act (relating to
non-discrimination) shall apply with respect to a group health plan or
health insurance issuer offering group or individual health insurance
coverage.

Note: A case is made here that this non-discrimination reaches into all self-funded ERISA plans, thus opening to over 50-million coverage of licensed integrative practitioners for services and procedures otherwise covered  when this provision takes effect in 2014.

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Speaker Nancy Pelosi: Without her, no HR 3590 and none of this inclusion

2. Inclusion of Licensed Complementary and Alternative Medicine Practitioners in Medical Homes

SEC. 3502. ESTABLISHING COMMUNITY HEALTH TEAMS TO SUPPORT THE
PATIENT-CENTERED MEDICAL HOME.

    (a) In General- The Secretary of Health and Human Services
    (referred to in this section as the `Secretary’) shall establish a
    program to provide grants to or enter into contracts with eligible
    entities to establish community-based interdisciplinary,
    interprofessional teams (referred to in this section as `health teams’)
    to support primary care practices, including obstetrics and gynecology
    practices, within the hospital service areas served by the eligible
    entities. Grants or contracts shall be used to–


      (1) establish health teams to provide support services
      to primary care providers; and

      (2) provide capitated payments to primary care
      providers as determined by the Secretary.


    (b) Eligible Entities- To be eligible to receive a grant or
    contract under subsection (a), an entity shall–

      (1)(A) be a State or State-designated entity; or

      (B) be an Indian tribe or tribal organization, as
      defined in section 4 of the Indian Health Care Improvement Act;


      (2) submit a plan for achieving long-term financial
      sustainability within 3 years;

      (3) submit a plan for incorporating prevention
      initiatives and patient education and care management resources into the
      delivery of health care that is integrated with community-based
      prevention and treatment resources, where available;

      (4) ensure that the health team established by the
      entity includes an interdisciplinary, interprofessional team of health
      care providers, as determined by the Secretary; such team may include
      medical specialists, nurses, pharmacists, nutritionists, dietitians,
      social workers, behavioral and mental health providers (including
      substance use disorder prevention and treatment providers), doctors of
      chiropractic, licensed complementary and alternative medicine
      practitioners
      , and physicians’ assistants;

Note:  The language in (4) is “may include” rather than “shall include,” which every legislator and lobbyist knows can mean the difference between night or day. Still, “may” puts one in the conversation.
 

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US Senator Barbara Mikulski: Steady advocate on numerous provisions

3. Integrative Health Care and Integrative Practitioners in Prevention Strategies

SEC. 4001. NATIONAL PREVENTION, HEALTH PROMOTION AND PUBLIC HEALTH
COUNCIL.

(d) Purposes and Duties- The Council shall–

      (1) provide coordination and leadership at the Federal
      level, and among all Federal departments and agencies, with respect to
      prevention, wellness and health promotion practices, the public health
      system, and integrative health care in the United States;

      (2) after obtaining input from relevant stakeholders,
      develop a national prevention, health promotion, public health, and
      integrative health care strategy
      that incorporates the most effective
      and achievable means of improving the health status of Americans and
      reducing the incidence of preventable illness and disability in the
      United States;

      (3) provide recommendations to the President and
      Congress concerning the most pressing health issues confronting the
      United States and changes in Federal policy to achieve national
      wellness, health promotion, and public health goals, including the
      reduction of tobacco use, sedentary behavior, and poor nutrition;


      (4) consider and propose evidence-based models,
      policies, and innovative approaches for the promotion of transformative
      models of prevention, integrative health, and public health on
      individual and community levels across the United States;


      (5) establish processes for continual public input,
      including input from State, regional, and local leadership communities
      and other relevant stakeholders, including Indian tribes and tribal
      organizations;

      (6) submit the reports required under subsection (g);
      and


      (7) carry out other activities determined appropriate
      by the President.


    (f) Advisory Group-

      (1) IN GENERAL- The President shall establish an
      Advisory Group to the Council to be known as the `Advisory Group on
      Prevention, Health Promotion, and Integrative and Public Health’
      (hereafter referred to in this section as the `Advisory Group’). The
      Advisory Group shall be within the Department of Health and Human
      Services and report to the Surgeon General.


      (2) COMPOSITION-

        (A) IN GENERAL- The Advisory Group shall be
        composed of not more than 25 non-Federal members to be appointed by the
        President.

        (B) REPRESENTATION- In appointing members under
        subparagraph (A), the President shall ensure that the Advisory Group
        includes a diverse group of licensed health professionals, including
        integrative health practitioners who have expertise in


          (i) worksite health promotion;

          (ii) community services, including community
          health centers;

          (iii) preventive medicine;

          (iv) health coaching;

          (v) public health education;


          (vi) geriatrics; and

          (vii) rehabilitation medicine.

        (3) PURPOSES AND DUTIES- The Advisory Group shall
        develop policy and program recommendations and advise the Council on
        lifestyle-based chronic disease prevention and management, integrative
        health care practices
        , and health promotion.


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Obama: Kept the pressure for the overhaul on Congress for months

4.  Dietary Supplements in Individualized Wellness Plans

SEC. 4206. DEMONSTRATION PROJECT CONCERNING
INDIVIDUALIZED WELLNESS PLAN.

Section 330 of the Public Health Service Act (42 U.S.C. 245b) is
amended by adding at the end the following:


    `(s) Demonstration Program for Individualized Wellness
    Plans-


      `(1) IN GENERAL- The Secretary shall establish a pilot
      program to test the impact of providing at-risk populations who
      utilize
      community health centers funded under this section an individualized
      wellness plan that is designed to reduce risk factors for preventable
      conditions as identified by a comprehensive risk-factor assessment.

      `(2) AGREEMENTS- The Secretary shall enter into
      agreements with not more than 10 community health centers funded under
      this section to conduct activities under the pilot program under
      paragraph (1).

      `(3) WELLNESS PLANS-


        `(A) IN GENERAL- An individualized wellness plan
        prepared under the pilot program under this subsection may include
        one
        or more of the following as appropriate to the individual’s
        identified
        risk factors:


          `(i) Nutritional counseling.

          `(ii) A physical activity plan.


          `(iii) Alcohol and smoking cessation counseling
          and services.

          `(iv) Stress management.

          `(v) Dietary supplements that have health
          claims approved by the Secretary.

          `(vi) Compliance assistance provided by a
          community health center employee.


        `(B) RISK FACTORS- Wellness plan risk factors shall
        include–


          `(i) weight;

          `(ii) tobacco and alcohol use;


          `(iii) exercise rates;

          `(iv) nutritional status; and

          `(v) blood pressure.

        `(C) COMPARISONS- Individualized wellness plans
        shall make comparisons between the individual involved and a control
        group of individuals with respect to the risk factors described in
        subparagraph (B).

`(4) AUTHORIZATION OF APPROPRIATIONS- There is
authorized to be appropriated to carry out this subsection, such sums
as
may be necessary.’

Note: This focus on the “individualized wellness plan” may have exceptional applications beyond dietary supplements.

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US Senator Bernie Sanders: Led in placing the workforce language

5.  Licensed Complementary and Alternative Providers and Integrative Practitioners in Workforce Planning

SEC. 5101. NATIONAL HEALTH CARE WORKFORCE COMMISSION.


(i) Definitions- In this section:


      (1) HEALTH CARE WORKFORCE- The term ‘health care
      workforce’ includes all health care providers with direct patient care
      and support responsibilities, such as physicians, nurses, nurse
      practitioners, primary care providers, preventive medicine physicians,
      optometrists, ophthalmologists, physician assistants, pharmacists,
      dentists, dental hygienists, and other oral healthcare professionals,
      allied health professionals, doctors of chiropractic, community health
      workers, health care paraprofessionals, direct care workers,
      psychologists and other behavioral and mental health professionals
      (including substance abuse prevention and treatment providers), social
      workers, physical and occupational therapists, certified nurse midwives,
      podiatrists, the EMS workforce (including professional and volunteer
      ambulance personnel and firefighters who perform emergency medical
      services), licensed complementary and alternative medicine providers,
      integrative health practitioners
      , public health professionals, and any
      other health professional that the Comptroller General of the United
      States determines appropriate.


      (2) HEALTH PROFESSIONALS- The term ‘health
      professionals’ includes–

        (A) dentists, dental hygienists, primary care
        providers, specialty physicians, nurses, nurse practitioners, physician
        assistants, psychologists and other behavioral and mental health
        professionals (including substance abuse prevention and treatment
        providers), social workers, physical and occupational therapists, public
        health professionals, clinical pharmacists, allied health
        professionals, doctors of chiropractic, community health workers, school
        nurses, certified nurse midwives, podiatrists, licensed complementary
        and alternative medicine providers
        , the EMS workforce (including
        professional and volunteer ambulance personnel and firefighters who
        perform emergency medical services), and integrative health
        practitioners
        ;

        (B) national representatives of health
        professionals;
        (C) representative of schools of medicine, osteopathy, nursing, dentistry, optometry, pharmacy, chiropractic, allied health, educational programs for public health professionals, behavioral and mental health professionals (as so defined), social workers, pharmacists, physical and occupational therapists,m oral health care industry dentistry and dental hygiene and physician assistant; …

Note: This is the one place where non-licensed integrative practitioners (Yoga therapists, certified homeopaths, etc.) appear to be referenced. Among the educational institutions noted in (C), only chiropractic of the distinctly licensed CAM fields with federally-recognized accrediting agencies is mentioned.


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US Senator Kent Conrad: Credited with working with Mikulski on CER language

6. Experts in Integrative Health and State Licensed Integrative Health Practitioners in Comparative Effectiveness Research

SEC. 6301. PATIENT-CENTERED OUTCOMES RESEARCH.

Part D–Comparative Clinical Effectiveness Research


(d) Duties-[Under (4)


      `(1) IDENTIFYING RESEARCH PRIORITIES AND ESTABLISHING
      RESEARCH PROJECT AGENDA-

        `(A) IDENTIFYING RESEARCH PRIORITIES- The Institute
        shall identify national priorities for research, taking into account
        factors of disease incidence, prevalence, and burden in the United
        States (with emphasis on chronic conditions), gaps in evidence in terms
        of clinical outcomes, practice variations and health disparities in
        terms of delivery and outcomes of care, the potential for new evidence
        to improve patient health, well-being, and the quality of care, the
        effect on national expenditures associated with a health care treatment,
        strategy, or health conditions, as well as patient needs, outcomes, and
        preferences, the relevance to patients and clinicians in making
        informed health decisions, and priorities in the National Strategy for
        quality care established under section 399H of the Public Health Service
        Act that are consistent with this section.

        `(B) ESTABLISHING RESEARCH PROJECT AGENDA- The
        Institute shall establish and update a research project agenda for
        research to address the priorities identified under subparagraph (A),
        taking into consideration the types of research that might address each
        priority and the relative value (determined based on the cost of
        conducting research compared to the potential usefulness of the
        information produced by research) associated with the different types of
        research, and such other factors as the Institute determines
        appropriate.


      `(4) APPOINTING EXPERT ADVISORY PANELS-


        `(A) APPOINTMENT-

          `(i) IN GENERAL- The Institute may appoint
          permanent or ad hoc expert advisory panels as determined appropriate to
          assist in identifying research priorities and establishing the research
          project agenda under paragraph (1) and for other purposes.

          `(ii) EXPERT ADVISORY PANELS FOR CLINICAL
          TRIALS- The Institute shall appoint expert advisory panels in carrying
          out randomized clinical trials under the research project agenda under
          paragraph (2)(A)(ii). Such expert advisory panels shall advise the
          Institute and the agency, instrumentality, or entity conducting the
          research on the research question involved and the research design or
          protocol, including important patient subgroups and other parameters of
          the research. Such panels shall be available as a resource for technical
          questions that may arise during the conduct of such research.


          `(iii) EXPERT ADVISORY PANEL FOR RARE DISEASE-
          In the case of a research study for rare disease, the Institute shall
          appoint an expert advisory panel for purposes of assisting in the design
          of the research study and determining the relative value and
          feasibility of conducting the research study.

        `(B) COMPOSITION- An expert advisory panel
        appointed under subparagraph (A) shall include representatives of
        practicing and research clinicians, patients, and experts in scientific
        and health services research, health services delivery, and
        evidence-based medicine who have experience in the relevant topic, and
        as appropriate, experts in integrative health and primary prevention
        strategies
        . The Institute may include a technical expert of each
        manufacturer or each medical technology that is included under the
        relevant topic, project, or category for which the panel is established.



(f) Board of Governors-


      `(1) IN GENERAL- The Institute shall have a Board of
      Governors, which shall consist of the following members:


        `(A) The Director of Agency for Healthcare Research
        and Quality (or the Director’s designee).

        `(B) The Director of the National Institutes of
        Health (or the Director’s designee).

        `(C) Seventeen members appointed, not later than 6
        months after the date of enactment of this section, by the Comptroller
        General of the United States as follows:

          `(i) 3 members representing patients and health
          care consumers.

          `(ii) 5 members representing physicians and
          providers, including at least 1 surgeon, nurse, State-licensed
          integrative health care practitioner
          , and representative of a hospital.


          `(iii) 3 members representing private payers,
          of whom at least 1 member shall represent health insurance issuers and
          at least 1 member shall represent employers who self-insure employee
          benefits.

          `(iv) 3 members representing pharmaceutical,
          device, and diagnostic manufacturers or developers.

          `(v) 1 member representing quality improvement
          or independent health service researchers.

          ‘ (vi) 2 members representing the Federal
          Government or the States, including at least 1 member representing a
          Federal health program or agency.



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US Senator Maria Cantwell: Sponsored the midwives’ provision

7.  Certified Professional (Direct-Entry) Midwives Covered in Birth Centers

SEC. 2301. COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES.

(a) In General- Section 1905 of the Social Security Act (42
U.S.C. 1396d), is amended–


      (1) in subsection (a)–


        (A) in paragraph (27), by striking `and’ at the
        end;

        (B) by redesignating paragraph (28) as paragraph
        (29); and

        (C) by inserting after paragraph (27) the following
        new paragraph:

      `(28) freestanding birth center services (as defined in
      subsection (l)(3)(A)) and other ambulatory services that are offered
      by
      a freestanding birth center (as defined in subsection (l)(3)(B)) and
      that are otherwise included in the plan; and’; and

      (2) in subsection (l), by adding at the end the
      following new paragraph:

    `(3)(A) The term `freestanding birth center services’ means
    services furnished to an individual at a freestanding birth center (as
    defined in subparagraph (B)) at such center.


    `(B) The term `freestanding birth center’ means a health
    facility–


      `(i) that is not a hospital;


      `(ii) where childbirth is planned to occur away from
      the pregnant woman’s residence;


      `(iii) that is licensed or otherwise approved by the
      State to provide prenatal labor and delivery or postpartum care and
      other ambulatory services that are included in the plan; and

      `(iv) that complies with such other requirements
      relating to the health and safety of individuals furnished services by
      the facility as the State shall establish.

    `(C) A State shall provide separate payments to providers
    administering prenatal labor and delivery or postpartum care in a
    freestanding birth center (as defined in subparagraph (B)), such as
    nurse midwives and other providers of services such as birth attendants
    recognized under State law, as determined appropriate by the Secretary.
    For purposes of the preceding sentence, the term `birth attendant’
    means
    an individual who is recognized or registered by the State involved to
    provide health care at childbirth and who provides such care within the
    scope of practice under which the individual is legally authorized to
    perform such care under State law
    (or the State regulatory mechanism
    provided by State law), regardless of whether the individual is under
    the supervision of, or associated with, a physician or other health
    care
    provider. Nothing in this subparagraph shall be construed as changing
    State law requirements applicable to a birth attendant.’…

Note: This is a provision hard-won by the MAMA campaign on behalf of Certified Professional Midwives (as distinct from nurse-midwives.

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Comment: These are not the only sections of the HR 3590 that may open opportunities for integrative practice or integrative practitioners.
There are, for instance, some potentially fascinating,
integrated care demonstration projects, and significant supports for community healthcare that may open opportunities.
In future issues, I will explore these potentially useful aspects of the law. Other than some additional inclusions of chiropractors or chiropractic schools, the above 7 segments are, to my knowledge, the places where integrative practices are most directly noted. Please let me know if I have missed anyth

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