Integrating CAM &Traditional Oncology

Integrating Complementary Therapies Into a Traditional Oncology Practice

David A. Shapiro, Mike Safer, M.D. Oncology Issues 17(1):35-40, 2002.

Introduction

Patients spend more money for non-traditional cancer treatments than for non-traditional treatments for all other diseases and conditions combined.[1] Studies have shown that many cancer patients are already using and paying out-of-pocket for complementary and alternative medicine (CAM) therapies.[2] These therapies can be profitable adjuncts to your oncology practice. They work harmoniously with traditional oncology treatment and can relieve some side effects of chemotherapy and surgery, boost the immune system, and relieve stress.

Physicians and practice administrators who are interested in integrating complementary therapies into their practice usually ask the same questions. How will an integrative oncology program benefit my practice? Where will we put the therapists? How will we find and hire them? What sort of financial arrangements should we make? How will we get the word out? Who will manage the day-to-day operations?

Unfortunately most physicians do not get past the question-asking phase. The majority of oncology practices are not effectively integrating complementary therapies, despite the fact that doing so can benefit patients, help improve patient satisfaction,[3] and offer promise for increased revenues, both from the therapies themselves and from increases in patient volume.

As word of your new therapy offerings spread, primary physicians and satisfied patients may refer others to your office. Integrated practices are currently hard to find, but the changing health care trends may drive more and more practices into this new realm.

The patient benefits are numerous. Patients like having all their care (both complementary and traditional) under the supervision of one trusted physician, and they appreciate not having to seek out complementary therapists on their own. Oncology patients report that complementary therapies promote relaxation, reduce cancer-related distress, help alleviate the side effects of conventional treatment, and actually empower them to take charge of their treatment and cope with the difficult circumstances the disease imposes on their families and their lives.

Recent research in psychoneuroimmunology has also shown that complementary therapies can boost the immune system.[4,5] Patient satisfaction and patient/doctor communications also improve when CAM therapies are used.[3]

Making The Case For CAM In Your Office

How strong is the demand for CAM therapies? Although physicians in one survey estimated that about 5 percent of patients see complementary therapists, the same survey showed that 83 million Americans (40 percent of the U.S. population) are using some form of alternative medicine therapies on a regular basis.[6] Only about half the patients said they discussed such treatment with their doctors,[3] because they thought their doctors would react negatively.[7]

According to a study presented at the 11th International Conference on Women's Health Issues in San Francisco, more than 70 percent of breast cancer patients use at least one type of complementary treatment (e.g., acupuncture, herbs, nutritional supplements, energy therapy, meditation). In another investigation, more than 66 percent of 411 breast cancer patients who answered a questionnaire used some sort of CAM therapy during or after their conventional treatment.[2]

According to a study in the Feb. 1, 2000, issue of the journal Cancer, of 46 men undergoing radiation treatment for prostate carcinoma, 37 percent used one or more complementary therapies while receiving their traditional treatment.[8] Estimates are that up to 85 percent of cancer patients have at least considered CAM therapies for treatment of their disease (including diet and vitamin therapy), often without the knowledge of their treating physician.[9]

Contrary to popular opinion, most patients are not seeking an alternative to traditional medical treatment. Some oncology patients want relief from the sometimes devastating side effects of conventional cancer therapies, a use that many physicians believe is promising. Others hope the treatments will help bolster the body's natural healing forces or alter the course of their disease, even if no reliable evidence yet exists.[10]

Two surveys conducted by David Eisenberg, M.D., of the Harvard Medical School documented CAM therapy use in 1990 and 1997. Eisenberg found a 47 percent increase in total visits to CAM providers (427 million in 1990 and 629 million in 1997) during that time period. In both survey years, the number of visits to CAM providers surpassed "the total visits to all U.S. primary care physicians." Eisenberg found that almost $14 billion was spent on these therapies in 1990 and $27 billion was spent in 1997.

This increase was attributable primarily to an increase in the proportion of the population seeking alternative therapies.[11] Projections are that this upward trend will continue in the future.[12]

The Official Attitude

The medical community is starting to take notice of these complementary and alternative approaches to care, and more holistic treatments are now part of the standard curriculum at certain medical institutions.[13]

Questions that patients were never asked before such as whether the patient experiences high or low stress, eats a high- or low-quality diet, exercises seldom or regularly, and has poor or healthy social relationships are now becoming part of intake exams.

Even the U.S. government is recognizing the paradigm shift in both the medical community and the general population and is making major changes in its spending patterns. The original 1992 budget of $2 million for the National Institute of Health's Office of Alternative Medicine was recently increased to $89 million in 2001, and the National Center for Complementary and Alternative Medicine (NCCAM) was established in the year 2000, with well-respected virologist Stephen E. Straus, M.D., as its director. NCCAM's mission is to research the safety and validity of complementary therapies.

It is in good company. Many highly acclaimed American universities -- Duke, Johns Hopkins, and UCLA among others -- have become involved in some type of complementary medicine research, the results of which are being put into practice at progressive facilities, including the Memorial Sloan-Kettering Cancer Institute, the Dana-Farber Cancer Institute, and the M.D. Anderson Cancer Research Center.

Taking The First Steps

The first step to integrating CAM therapies into your practice is to find out what treatments your patients are already using. Ask patients about their experiences, learn which therapies they would like to explore, and find out what they expect from these treatments. Ask patients to list any vitamins and herbs they are taking on intake exams, and learn about the positive and potentially negative effects of these supplements.

This dialogue will automatically open the doors of communication between you and your patients, and assure them that your oncology practice respects them and is attuned to their needs.

After you and your staff have chosen the CAM therapies you are comfortable including in your practice and have learned as much as you can about them, you should develop professional relationships with practitioners of these therapies who can work together with you and your patients.

Most physicians and office staff know how to find a good physician assistant or nurse, but have no idea how to locate a massage therapist or a Reiki master. Complementary practitioners often advertise in the yellow pages, vegetarian restaurants and cooperatives, holistic healing organizations, and holistic nursing associations. There may even be a CAM therapy school in your area.

Many such schools have web sites and will provide the names of qualified practitioners in your area. Typing the name of the therapy into several search engines should allow you to find the organizations you seek. Your patients are also an excellent source of referrals because they are already using these specialists.

After finding several seemingly qualified candidates, check their professional references and job history, contact current clients, and obtain character references. The hiring process should be as careful and exacting as the one you would use for any other staff member who treats patients. Ask for a hands-on demonstration, and make sure the demo "patient" has enough experience with the particular therapy to know if the practitioner is doing it well.

You should also have a trusted person visit the therapist's office to get a feel for how they practice.

Whether you are considering hiring therapists as independent contractors or hourly employees, make sure you check your individual state and federal laws. These laws are not always clear-cut. In general, you are required to hire CAM therapists as employees if you give them specific instructions and guidelines necessary to perform the job.

This will most probably be the case since treatment will be a joint effort. Pay therapists by the patient visit so you are guaranteed revenue each time you pay out. If they remain part-time employees, you do not need to provide benefits, but their wages will be subject to withholding.

Many therapists are often looking for consistent hours to fill in their weekly schedule, so the arrangement to employ them on a part-time basis will be mutually beneficial for the therapist and the facility.

Salaries for therapists vary by region. Licensed nutritionists in the high-priced Northeast often command $35,000 per year for full-time work. A massage therapist typically charges $30-$40/hour in the Southeast. Acupuncturists' salaries vary widely by state, depending on whether they must be medical doctors or medically certified.

No matter where your practitioner's fees are on the scale, there will still be enough margin to generate significant revenue from having any or all of these therapists as part of your staff.

Space and Education

If your practice has no additional therapy rooms, an integrative program is still possible. Few facilities have extra space they do not use, and exam rooms can easily double as treatment rooms in offices where space is at a premium.

CAM therapists commonly work with patients just prior to, just following, or even while they are receiving their traditional treatment.

Since most therapies are received in street clothes, they do not have to be delivered in "curing closets." Open areas are usually all that is needed. If CAM therapies are performed in open areas, other patients see the treatment being given, which may make them more likely to try the therapy themselves (especially when satisfied patients relate how much better they feel).

Chemotherapy suites make ideal treatment rooms for acupuncture, guided imagery, seated massage, reiki, reflexology, and many other complementary therapies. Some therapies, such as acupuncture, require the patient to lie down. In these cases, a treatment table in the open area may suffice. Just make sure that there is at least two feet around the perimeter of a standard 3' x 6' treatment table to allow the therapist to work, plus room for a chair/wheelchair.

Portable treatment tables that can be folded up and put away when not in use are a great space saver. If patients need to be gowned during treatment, then a privacy curtain or a small room, not much larger than the table itself, is all that is required.

After the CAM therapists are hired, have them perform an in-service teaching session so that you and your staff understand what they are doing. Then teach your new therapists about your practice.

Review office policies, procedures, and expectations; and make sure they thoroughly understand conventional treatment and its side effects, how their therapy might negatively interact with conventional treatment, and other possible contraindications. Test all therapists on the material covered in the in-service before they meet with patients to make sure they have mastered the information.

Education is the key to program success and expansion. You must educate (or hire someone to educate) both your staff and your patients. Informed staff members can discuss possible CAM alternatives with patients who have never used CAM therapies before, and educate them about the new possibilities that are available. Some facilities have their therapists do workshops for employees as well as patients and family members.

This method can effectively promote your program at the same time it teaches your staff how beneficial these therapies can be.

An outstanding marketing tool is to have your massage therapist give demos of seated massage in the waiting area or chemo suite during a Patient Appreciation Day. If you want patients to use your newly added services and want your staff to become excited about adding this program, you will need to educate, educate, educate.

Marketing and Reimbursement

Once you find your practitioners, it is then time to market the new program and let your patients and community know what you are offering. The media are always looking for health care-related news, so present your integrative oncology program in an interesting manner and tell your story. You should be able to get significant press coverage for the best price: free.

A critical component of successful integrated practices is continuous improvement. Patient satisfaction surveys -- either by phone or mail -- can help to identify improvement areas on an ongoing basis. You want to make sure you are meeting the needs of your patients, and this tool is an excellent way to monitor your progress.

A survey can let you know as soon as possible if a therapist is not satisfactory, properly trained, or doing a good job of promoting the therapies and their potential benefits.

Patients using CAM therapies are usually paying for them out of their own pocket. Most insurers do not pay for CAM therapies, but some will cover counseling, nutrition, acupuncture, and massage. Our usual recommendation is to offer therapies on a fee-for-service basis and provide patients with "Superbills" to submit to their insurers.

Superbills are the total of all services provided over a certain time period, typically one month. They not only cut down on paperwork, but also show insurers that both traditional and complementary therapies are being used in the overall treatment plans of the patients, all under the supervision of the attending physician. Insurers may be more apt to pay in these circumstances.

Implementing Your CAM Program

Whoever leads your CAM integration effort should have extensive experience in complementary therapies, marketing, patient management, and program implementations, plus excellent organizational and communication skills. Find either an employee who has these qualifications and wants to manage the integration, or hire an external consultant. Devoting adequate time to implementing, maintaining, and improving your CAM program is essential for success.

Professional consultants can cost anywhere from $10,000 plus expenses to $50,000 or more depending on the scope of the program you desire and the service options you choose. Options include feasibility studies, profit projections, patient focus groups, recruiting complementary practitioners, staff training, community relations, marketing, patient education classes, open houses, and the monitoring and management necessary for continuous improvement.

Many practices have established subcommittees that meet regularly to discuss complementary therapy integration, and some are performing feasibility studies as a first step. Consultant fees can be value/project-based, daily, or hourly. A value-based fee allows you to know what the project cost is going to be up front.

No meter is running and you don't have to worry about billable time. With value-based fees, it is in everyone's best interest to work efficiently and effectively.

The success of your program will depend on the skills and dedication of the individuals involved in its implementation. Do it correctly from the beginning, and CAM therapies can become a major source of revenue for your practice. Do it wrong, and it will wind up costing you more than you planned.

If you are currently examining the latest trends and statistics regarding integrative therapies and cancer care, you are in good company. Those who implement this type of program within the next couple of years may be called trendsetters; but in the not-too-distant future integrated oncology programs may become standard practice and considered true comprehensive cancer care.

References

Lenny Lecture: Focuses on the science of complementary therapies. Inside Inst. Dana-Farber Cancer Institute. December 5, 2000.

Boon H, Stewart M, Kennard MA, et al. Use of complementary/alternative medicine by breast cancer survivors in Ontario: prevalence and perceptions. J Clin Oncol. 2000;18:2515-2521.

Oldendick R, Coker AL, Wieland D, et al. Population-based survey of complementary and alternative medicine usage, patient satisfaction, and physician involvement. South Med J. 2000;93(4):375-381.

Shrock D, Palmer RF, Taylor B. Effects of psychosocial intervention on survival among cancer patients with stage 1 breast cancer and prostate cancer: a matched case-control study. Altern Ther Health Med. 1999;5(3):49-55.

Simonton SS, Sherman AC. Psychological aspects of mind-body medicine: promises and pitfalls from research with cancer patients. Altern Ther Health Med. 1998;4(4):50-54.

Landmark Healthcare Inc. The Landmark Report on Public Perceptions of Alternative Care. Sacramento, Calif.: Landmark Healthcare; 1997.

Eliason BC, Huebner J, Marchand L. What physicians can learn from consumers of dietary supplements. J Fam Pract. 1999;48:459-463.

Kao GD, Devine P. Use of complementary health practices by prostate carcinoma patients undergoing radiation therapy. Cancer. 2000;88(3):615-619.

Kaptchuk TJ, Eisenberg DM. The persuasive appeal of alternative medicine. Ann Intern Med. 1998;129:1061-1065.

Richardson MA, Sanders T, Palmer JL, et al. Complementary/ alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol. 2000;18:2505-2514.

Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280:1569-1575.

Ernst E, Cassileth BR. The prevalence of complementary/ alternative medicine in cancer: a systematic review. Cancer. 1998;83:777-782.

Wetzel MS, Eisenberg DM, Kaptchuk JJ, et al. Courses involving complementary and alternative medicine at US medical schools. JAMA. 1998;280:784-787.

NIH Consensus Developmental Panel on Acupuncture. JAMA. 1998;280:1518-1524.



David Shapiro, D.C., is a speaker, writer, and consultant. He is the founder of The Integrative Advantage in Atlanta, Ga., which provides turn-key complementary medicine programs that can be integrated into traditional oncology settings. Mike Safer, M.D., is a radiation oncologist with more than 25 years of practice experience. He is the director of two cancer centers in the Southeast and a member of The Integrative Advantage team.

Contact The Integrative Advantage at (404) 231-9931 or through its web site at www.integrativeadvantage.com.


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