Summary: Integrative care and consumer health maven Stephen Bolles, DC found the Integrator’s 8 trends favoring integration of integrative practices “accurate but incomplete.” The missing ingredient in Bolles view: the consumer. In this column, Bolles first sets up his case, his soapbox as he calls it. Then he takes us through each of the 8 trends – the rise of nursing, CER, patient-centered care, interprofessional education, etc. He re-writes each through the prism of this marketplace perspective. The result is a useful reflection that not only leavens whatever value was in the initial column. Bolles’ piece also releases some of the darker underside of trends that were presented, originally, with perhaps too rose-colored of glasses. Your comments?
Was the consumer appropriately represented in the 8 trends for integration?
The Integrator column on the Top 8 Trends in Favor of Integration of CAM and Integrative Practice Disciplines provoked a quality response column from Stephen Bolles, DC. Bolles found these trend-lines “accurate but incomplete.” He argues that they miss an essential ingredient: a marketplace and consumer focused perspective. Bolles took the 8 trends and re-shaped them around this key shift in healthcare. Writes Bolles: “I think the secret sauce in integrative practice business successes at this point: too
little attention is paid to what the market is really hungry for.”
your citation of the top eight trends, I think you have done a good job
identifying them and perhaps the hierarchy as well. One thing that I think is
missing, and perhaps my central ‘soapbox’ issue these days, is the lack of
orientation of these trends toward marketplace (consumer) dynamics.
healthcare marketplace–a marketplace increasingly characterized by retail
dynamics in the purchasing, consumption, organization of information, perceived
value and relationship management associated with health care services–the
trends you cite are accurate, but to me are incomplete. They are pretty much
oriented to the supply side of the supply/demand position the system and
consumers occupy. In my view we providers are part of the supply side, whether we
like the company that puts us in with or not. I see little evidence of an
orientation of integrative efforts toward marketplace dynamics–one of perhaps
the key reasons why so few (any?) academically-grounded integrative practices
are viable self-sustaining businesses. Why is Massage Envythe
national example of a CAM business chain success?
” Marketplace dynamics probably need
to be factored in to every trend you cite,
because they certainly effect a kind
gravity on how the trends play out.”
intending to strip integrative practice efforts of their soul or spirit, as I
see it integrative practices are essentially delivery models, and what gets delivered
has to be what the market wants, or it is simply unsustainable. I think that’s
the secret sauce in integrative practice business successes at this point: too
little attention is paid to what the market is really hungry for. I see a lot
of energy going into refinements of what we providers want to believe the
market should want, and a lot of professional certainty that the better
mousetrap is to figure out how to convince consumers we’re right.
But I do not know of any data-grounded reality check on that orientation, one
that probably will in hindsight be assigned a place in history that is further
from professional insight than we might like and closer to hubris.
me, the relevance of this approach is that marketplace dynamics probably need
to be factored in to every trend you cite, because they certainly effect a kind
of gravity on how the trends play out. Just a quick snapshot of some of the
effects from my (probably distorted, but deeply convicted at this point in my
are aging, but so is their patient cohort. Older adults went in ten years from
being the group most likely to trust physicians to the group least likely to
trust them–in particular, with details of their consumption of CAM services.
They weren’t asked, so they stopped telling. They get asked, they tell. Without
being asked, they take their consumption choices elsewhere.
“If nurses establish a strong footing
in this role with consumers,
be scrambling to develop stronger
relationships with them
of us currently pay attention to.
nursing professional visibility in the crunch of medical work-force challenges
isn’t, I would submit, an accident of the economics of specialty medical care
bleeding off general practitioners. It’s perhaps true that it’s gained momentum
because, in part, nurses are the profession historically aligned with
compassion, sympathy and empathy toward patient needs. The rest of us are
pretenders. If nurses establish a strong footing in this role with consumers,
we will, I expect, be scrambling to develop stronger relationships with them
than most of us currently pay attention to.
relationship of the To Err ugliness to consumer market dynamics is very
weak at this point–but when consumers really start to wake up to their version
of the impact of this area of problems, I think that a fair amount of latent
anger is going to surprise people.
effectiveness research has always seemed like the Holy Grail, in different
forms, to CAM professions. I remain hopeful that ultimately it makes a
difference. That hope is (unfortunately) tempered by the lack of systemic
change that the CER to date has created; and frankly, there’s been some pretty
good data. I simply think that the proportionate contribution of CER weighed
against the implications of the deep shift in political control makes the
financial arguments seemingly compelling, but ultimately ineffective
sources of leverage. At least, until the system itself is held accountable for
inefficiencies in these areas, I still don’t see CER playing as much of a
change agency role as we want–and certainly have the right to expect. The same
data, however, ported to the emerging retail consumer health care marketplace,
can make changes very, very quickly. We just haven’t learned, in my view, how
to talk to our customers about it. We keep trying to talk to Daddy Warbucks.
of what passes for ‘patient-centered’
descriptors makes me want to gag–because
it’s the system’s version of what patients want.”
of what passes for ‘patient-centered’ descriptors makes me want to gag–because
it’s the system’s version of what patients want (do they even want to be called
patients??). A consumer-facing version of all this probably makes too many
providers uncomfortable because of how much the model(s) will end up needing to
emulate retail, customer-service driven environments, but that’s our problem,
3. The Affordable
Care Act certainly may foster increased availability and accessibility of
integrative options to consumers–but the aggregator of those options may still
not help us as much as we’d like or want to think. There is still a gap, I
believe, between the availability of these services and the economics of their
delivery–which will likely be a big part of what consumers decide to use as
they vote with their pocketbooks in the presumably more-diverse health services
purchase world of state-based exchanges and the new business models they
reward. That gap may be easily bridged as these market dynamics grow
stronger–or we may find that the cultural gap in the current system persists,
to our (and our patients’) detriment.
“I would submit that we are still
missing the now-collective
to refine how we use our emerging
leadership roles in health care
consumers understand the real
opportunities of integration.”
2. I am
a passionate proponent of academic center integration–no matter which side of
the cultural divide we’re positioned on. I simply can’t see any benefit to wars
over scope, and the clawmarks of the legal and legislative battles make deep
and difficult wounds to heal. I believe that consumers want an ecumenical
approach to service options. And I am more convinced now than I was a decade
ago of the belief that we still need to figure out how to describe the value of
our services to consumers as a focused contribution to clinical needs, rather
than the marketing efforts that seek to elbow out of the way other providers
with overlapping scopes of practice and potentially competitive therapeutic
benefits. If we ever figure that out, I think consumers will reward us very
well. The implications for that approach to as professions seems to be one we
simply cannot even entertain without painful intraprofessional battles.
1. The Institute
for Alternative Future’s report on Chiropractic and its position in the
marketplace based on its futures modeling back in the early 1990’s was
prescient–and largely not capitalized on by chiropractic. The version of what
the IAF identified that we should take as a collective dope-slap was their
understanding that wellness would emerge as a basis for consumers to make key
spending and relationship decisions about the health care services they consume–and
whom they seek them from. The professional market for this, based on the
variety of responses from all health care professions is probably defiantly
disaggregated. I would submit that we are still missing the now-collective
opportunity to refine how we use our emerging leadership roles in health care
to help consumers understand the real opportunities of integration. That lack
of agreement on our part as providers has left consumers alone to figure it all
out. They are probably showing early signs of accepting that role. Whether they want us as leaders may be a very important assumption to test.
thanks for listening! That’s my soapbox–and probably a perspective most will
not value or agree with. But
it’s my soapbox; my feet fit and I’ve grown to like the view!
Comment: The marketplace and the consumer have been Bolles’ soapbox for some years now. I don’t know if it predated his time trying to work with a consumer focus inside UnitedHealthcare. It’s certainly been since. I must say that every time I encounter his views, I have that uneasy feeling that I’ve been walking around with my zipper down. The level of embarrassment (more than that from, say, having it pointed out that one has a little food left at the corner of the mouth) is related to the depth of the paradox. The integrative care disciplines uniformly see themselves as evolving in close connection to consumer demand. Are they/we disconnected from this birthright? More particularly, are struggles with establishing successful integrative care business models linked to losing consumer-ese, our mother tongue? Thank you Dr. Bolles for sticking to your soapbox. Maybe some of us will begin to incorporate this thinking.
8: The Old Finally Die – and they get sick and use CAM before they do
A bastardization of a famous comment on the evolution of
scientific throught is that things change when the older generation
finally dies. The new generation of medical doctors is more likely to
have grown up in families that used some forms of “alternative
medicine.” Younger MDs are also more likely to be women. They are
typically friendlier toward functionally-oriented explorations of new
ways to find health. At the same time, because use of non-conventional
care is typically highest among those who have frank conditions, even
the curmudgeons among the waning generation may soon be integrating new
therapies and providers as their healths decline.
7: RWJF-IOM’s liberation from MD control for nurses and perhaps others
The October 2010 Robert Wood Johnson Foundation (RWJF)-funded and Institute of Medicine (IOM)-published report, The Future of Nursing: Leading Change, Advancing, was not only an Integrator Top 10
for 2010. As a declaration of independence for nurses from MD oversight
and control, that report may be the most significant policy document in
US medicine since Abraham Flexner.
MDs have been lousy at sharing authority. Expect more from the nurses.
Expect more also from MDs once the get accustomed to the new sharig of
control. By piercing the AMA power-bubble and charging nurses to step
up, the RWJF-IOM report also opens the potential for other disciplines
to play significant roles in “leading change.”
6. To Err is Human and the rise of interprofessional education (IPE)
The IOM’s shattering 2000 report To Err is Human: Building a Safe Health System brought medical deaths out of Davey Jones’ locker.
The search for solutions is highlighting poor communication between
practitioners and disciplines. The need is for more mutual respect and
teamwork. A strategy: enhancing what has become known as
interprofessional-education (IPE). While the U.S. is basically a
generation behind Britain and Canada, Obama’s administrator for the
Health Resource Services Administration, Mary Wakefield, RN, PhD, is presently championing IPE. The American Interprofessional Health Collaborative
is beginning to carry the movement nationally. One anticipates more
ease in integrating non-conventional practitioners if one already living
an ethos that affirmatively opens up peripheral vision to others.
5. Comparative Effectiveness Research (CER) and PCORI
This is the system is collapsing of its own weight so we’re finally going to focus on the real world
trend. The approach focuses on better ue of what we have, including the
non -conventional, rather than putting our eggs in some savior dressed
up as a magic bullet or tweaked gene. Complementary and alternative
medicine and integrative practices are specifically acknowledged as
important topics for CER and in the huge new Patient Centered Outcomes Research Institute (PCORI). Inside the CAM universe, NIH NCCAM is finally looking at the “real world” in its 3rd strategic plan.
The relevant NCCAM objective includes focusing on the integration
of these disciplines into the delivery system. The plan hs a historic
focus on disciplines. This direction may finally generate the data to
support stakeholders on integration decisions – the central purposed of
US Senator Harkin’s mandate in setting up NCCAM.
4. Patient-centered care and the karma of non-inclusion
The claim of patient-centeredness, from medical homes to optimal inpatient healing environments, is at the rhetorical center of U.S. healthcare. Given the known use of integrative and ‘CAM” practitioners by
a significant subset of patients, one might assume that, sheesh, a
patient-centered world would naturally reach out to include at least the
licensed ‘CAM” folks: chiropractors, acupuncturists, naturopaths,
massage therapists and homebirth-oriented midwives. One purported
principle of a medical home is a whole person orientation in
which the lead practitioner “is responsible for providing for all the
patient’s health care needs or taking responsibility for appropriately
arranging care with other qualified professionals.” Patient-centered care advocates will have karma issues if they don’t integrate these other providers. Are you patient-centered or are you not?
3. Inclusion of integrative and licensed “CAM” practitioners in the healthcare reform law
Whatever else once thinks of the Obama Affordable Care Act, a single-issue voter who cares principally about opening access to CAM and integrative practices has got to like the historic inclusion of integrative and CAM practices in numerous sections
of the law. Chiropractors and licensed CAM practitioners were
legislated a right to be included in workforce planning, in prevention
and health promotion, in CER (noted in the PCORI initiative, above), in
delivery (medical home pilots) and even in payment, via a
non-discrimination clause. Each is a stone in a lake with far-rippling,
integrative effects, if acted upon appropriately.
2. Integration in the missions of multidisciplinary CAM universities
The last decade has seen the emergence of the multidisciplinary
university of natural health sciences. The seed in each case was a
single purpose chiropractic or naturopathic college. Now the National
University of Health Sciences, Bastyr University, Northwestern Health Sciences University, Southern California University of Health Sciences,
and, to a lesser extent, institutions like New York Chiropractic
College, Tai Sophia Institute and University of Western States are each
wrestling with integration internally . For the most part, each is also
declaring leadership in integration in newly wrought mission
statements. Expect them to be a base for this movement from the natural
1. “CAM” and integrative care leaders stepping up as simple healthcare leaders
An early presenter at the ACC-RAC argued from the podium that the work
in integration is best undertaken not to promote chiropractic but to
promote optimal health care. The focus is developing better care,
period. This leadership concept is beginning to be seen elsewhere. Such a
leadership ideas is front and center with CAM researchers working to
shape an optimal research agenda. The best strategies for examining
whole practice, practitioner-delivered health promoting outcomes will
most likely emerge if the researchers from these field step with two
feet into the muddy dialogue, prtner with conventional colleagus, and
urge their colleagues to do the same. CAM
discipline and integrative MD leaders who roll up their sleeves to
shape an emerging system of care are key to integration of the
disciplines. The rising spirit is Kennedyesque: If not now, when, if not us, who?