John WeeksSummary: 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.
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
- Put http://thomas.loc.gov/ into your browser.
- Look on the right under “Weekly Top 5” and click on on H.R. 3590.
- Click onto Text of Legislation.
- Click into the 7th and final version of the bill. This will guide you section by section.
Here’s hoping this is useful.
Patient Protection and Affordable Healthcare Act (HR
3590)
to call out the specific language.
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.
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.
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.
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.
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.
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.
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.
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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johnweeks@theintegratorblog.com
for inclusion in a future Your Comments Forum.
Dr. Judith Orloff MD
Barry Bittman MD
Dr Jacob Teitelbaum MD