This article appeared in the August 1, 2003, issue of Puget Sound Business Journal
IN DEPTH: HEALTH CARE QUARTERLY
Patients push for doctors and naturopaths to interact and blend the best treatments
Beth Taylor
Contributing Writer

Recently 22 medical students from around the country and several nursing-faculty members from the University of Washington converged on Bastyr University to attend its second annual Complementary and Alternative Medicine camp.

These conventional-medicine practitioners set foot on the Kenmore campus of the nation's largest natural-medicine school to keep up with a patient-driven trend: better cooperation between alternative and traditional health-care providers.

"I think it is important that we work more closely together, whether or not we agree with each other, for the patients' benefit," said Ron Schneeweiss, director of a grant program at the University of Washington to study alternative medicine, which was funded by the National Institutes of Health. "We are not teaching our physicians to become complementary-medicine providers. We are teaching them how to communicate about it with their patients without being pejorative, and how to communicate with alternative-medicine providers."

That's increasingly important, because a study published last year by the Fred Hutchinson Cancer Research Center found that 70 percent of Western Washington residents with cancer had used some type of alternative medicine, ranging from naturopathic treatment to massage therapy to herbal supplements.
"The people who used alternative medicine felt that they dramatically improved their general health," said Ruth Patterson, a Ph.D. in Fred Hutchinson's Public Health Sciences Division who led the study. "Your assumption (as a physician) has to be that your patients are using some sort of alternative medicine. If you're concerned about interactions with your traditional care, you should be able to talk to them about it."

Interest in alternative health care is on the rise nationwide, but has always been strong on the West Coast, perhaps because of its proximity to Asia and its Chinese medicine traditions. Washington is one of the few states that license naturopaths, and one of a half-dozen states that require insurance companies to provide at least some coverage for naturopaths, acupuncturists and massage therapists.

But there have been court struggles in Washington since the "Every Category of Provider" law was passed in 1996, as insurance companies balked at providing additional benefits or interpreted the new law differently from their policyholders. After the state Supreme Court upheld the law in 2000, Regence BlueShield and Premera Blue Cross agreed to settlements reimbursing consumers for alternative care they had received since 1996. And in June, state and federal courts okayed a settlement in which Group Health will reimburse about 100,000 policy-holders for care they received from state-licensed alternative-medicine providers.

"This state is more friendly than most to naturopaths because of all the legal protections," said Michael Schiesser, M.D., an internist whose clinic, Moss Bay Center for Integrative Medicine in Bellevue, includes both alternative and conventional practitioners. "The health-care consumer often isn't concerned about the difference between alternative and traditional. They just want what works."

Notes Bastyr spokeswoman Kathleen Warren: "Because Bastyr is the best-known and the biggest (natural-medicine school) and because Washington state was the first to require insurance coverage for alternative medicine, that puts Washington in the forefront of alternative medicine. Whenever you have insurance access, you also have more access to the medicine."

But alternative practitioners are still typically reimbursed at much lower rates than conventional providers, even in Washington, and so far are not covered at all by Medicare or Medicaid. And insurance paperwork and treatment codes are often problematic for nontraditional practitioners.

"We're still learning how to work with the insurance system," said Christy Lee-Engel, an N.D. at One Sky Medicine, an integrative practice in Seattle. "We're restricted to a certain extent by the codes the insurance companies will pay for, so many of us give much of our services away. We tend to spend much more time with our patients. Insurance companies don't really reimburse for time anymore, they just reimburse for complexity. So what we might consider complex, as far as taking all aspects of the patient's life into consideration, might sound like something simple as a diagnosis, like fatigue."
And insurers may limit the number of alternative providers they include in their plans. Those who do get accepted into HMO or PPO plans must undergo a rigorous credentialing process, which includes making certain they have access to emergency care if their patients need it. Although naturopaths may serve as primary care physicians in Washington, providing such services as yearly exams, blood pressure and cholesterol checks, pap smears and prostate exams, they do not have admitting privileges at hospitals.

Alternative-care providers who practice in an integrative clinic or work closely with a cooperative hospital, therefore, have an advantage when it comes to qualifying for insurance plans, because the medical doctor can advise them on the credentialing process and provide access to emergency facilities. Working with a medical doctor can also enhance the status of alternative-care practitioners in the eyes of many patients.

On the flip side, cross-referring to alternative practitioners gives medical doctors something else to offer their patients who want to pursue nontraditional options. And opening the topic up for discussion allows conventional providers to explore the possibility that their patients are already using alternative treatments that need to be taken into account.

"From a business standpoint, I think it helps patients to have confidence in us to know I'm open-minded enough to practice with an acupuncturist, and for the acupuncturist to have the credibility of practicing with me," said Schiesser.

Dr. Ben Chue, an oncologist who grew up in a Chinese family in California, says he benefited from the best of both medical worlds and likes to pass that advantage along to his patients.

"My family used Chinese medicine when we thought it was more appropriate, and Western medicine when it worked better. To us, it was never a dilemma."

Chue went to medical school at the University of California at San Francisco and did his residency at Fred Hutchinson. He now practices at the integrative Seattle Cancer Treatment and Wellness Center, where medical doctors work alongside naturopaths, acupuncturists, nutritionists and massage therapists. He might refer a cancer patient to an acupuncturist for pain relief or a nutritionist to help reduce the side effects of cancer treatments.

The beauty of an integrative-medicine practice, he says, is that every type of practitioner knows how all the others are treating a particular patient. Chue says some medical doctors at nonintegrative clinics may not think about possible drug interactions with herbal supplements. Because some interactions are dangerous, he says, it's important that doctors inquire about all the products a patient might be taking.

Still, he says, the traditional medical community is making great strides toward increasing its knowledge of alternative medicine.

That's partly because recent studies have allayed some of the misgivings of mainstream medicine when it comes to alternative treatments.

"Except for the concern about interactions, I don't think it's a huge issue now," said Patterson. "The studies have not found that people are abandoning conventional medical treatment, instead they're adding alternative care."

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