Integrative medicine clinic requires solid business plan. (Integrative Medicine).

In an article that appeared in the January/February 2003 issue of The Physician Executive, health care futurist Leland Kaiser declared, "Alternative or holistic medicine should be called appropriate medicine."

In the same article, futurist Russ Coile predicted, "Consumers are saying it's [integrative medicine] important" and, as one of the top 25 future health care trends, "this is going to be the way medicine is going to be practiced in 10 years."

I agree. As a physician executive, I believe the real question is not whether integrative medicine will be part of the future, but rather how are we going to do it?

I have been involved with integrative medicine for the last dozen years as the president and CEO of a medical group, program director, and medical management consultant integrating conventional allopathic medicine with complementary and alternative medicine.

It had been my dream since medical school three decades ago to be involved with integrative medicine. When I was invited in late 2001 to bring my clinical practice and medical management consulting to Integrative Medical Clinic (IMC) in Sonoma County, Calif., I jumped at it.

IMC's plan for 'appropriate' medicine

IMC's vision was to adopt a bold strategy to organize and execute an integrative medical model. Surveys suggested that up to 70 percent of the local health care market was interested in such a product. Integration was to occur at multiple levels. IMC's intent was to synthesize:

* Modern technology and perennial wisdom

* Powerful and definitive treatment and compassionate care

* Western and Eastern

* High technology and folk healing traditions

IMC is based on the belief that each patient is a unique, whole person--biological, psychological, spiritual--in a total social and ecological environment. The idea is that healing should be a fully collaborative partnership where teaching is as important as treatment, and self-care--particularly through self-awareness, relaxation, meditation, nutrition and exercise--is the true "primary care."

Planning integration

Joining IMC just six months after it opened, my initial assessment was that it had all the ingredients for success.

Twenty health practitioners had met monthly for two years of planning before launching IMC in our community of 150,000 in northern California. The four board-certified family physicians were assistant or associate clinical professors of family medicine at the University of California San Francisco. The medical director was past family practice residency director and active as the family practice residency medical education director. Most of the 15 complementary and alternative medicine providers had local solo practices prior to merging into IMC.

In the fail of 2001, IMC opened in 7,500 square feet of newly modeled space designed with a "Western" medicine wing for four family physicians, one nurse practitioner and two chiropractors.

An "Eastern" medical wing included three integrative psychotherapists, a hypnotherapist, biofeedback specialist, two nutritionists, four massage/body workers (with special training in Hanna and Feldenkrais somatic re-integration therapy), an herbalist and an acupuncturist medical doctor.

Several naturopaths were interviewed for potential recruitment to the clinical team. However, mostly because California does not license such practitioners, they were not included. One is being recruited now as is an ayurvedic medical practitioner.

Real integration

Clinical integration of these complementary and alternative therapies was engineered through almost weekly meetings structured around building solid team spirit and to familiarize various practitioners with each other's therapies.

This is an important point for physician executives: actively structure ways that practitioners from different traditions can spend time together and personally experience acupuncture, massage, chiropractic, guided imagery, etc.

Navigator concept

A social worker/case manager called a "navigator" evaluated IMG's patients. A nurse practitioner, social worker or allied mental health worker can fill this navigator role.

After an in-depth assessment that included a 90-minute interview and analysis of medical information from prior providers, the navigator presented the cases at bimonthly patient-care conferences. The navigator then constructed an integrative medicine plan designed to coordinate different types of care.

Over time, the practitioners became familiar with all the therapies and team members' skills. These conferences were indispensable in developing an effective integrative medicine program. The clinical team found that the cross-discipline education helped them see how they could improve the treatment of other patients and provide more appropriate internal referrals.

It was one of the most enjoyable parts of working together.

Patients

Patients at IMC were all ages, both genders, and from varied socioeconomic backgrounds.

After the only HMO plan that IMC participated in declared bankruptcy in IMC's sixth month of operations, IMC decided to only accept courtesy billing. Patients were expected to pay at the time of the visit and IMC billed for the service as a courtesy only, including Medicare. The insurance company then reimbursed the patient.

While this cash-based orientation is often adopted by integrated clinics across the country, I think physician executives need to learn how to develop better relationships with payers to address patients outside of the small niche who are able to pay for services Out of pocket.

Treatments

A patient at IMC with intractable migraines might have the usual Western medical therapies prescribed by the physician along with herbal therapies such as feverfew, valerian, acupuncture, meditation relaxation/biofeedback, psychotherapy and nutritional care.

A diabetic would receive nutritional therapy augmented by movement therapy (Ghi Gong, Tai Ghi, Yoga), guided interactive imagery and herbal therapy (guggulipid for hyperlipidemia).

Patients might list their acupuncturist or chiropractor as their primary care providers, and while most patients saw MDs as well, some actually had their primary MD outside the clinic.

IMC's goal is to provide primary care as well as consultative "integrative medicine specialty" care for outside referring physicians.

Results

Patients experienced breakthroughs in multiple medical conditions including pain management, cardiovascular disease, hepatitis C and depression.

While some of this effect is related to the use of specific treatments, I believe some is dependent on the clinical integration of the provider team.

For example, as recommended by the National Institutes of Health, a formal and effective pain rehabilitation and education program designed as an intensive, multidisciplinary 12-week treatment plan for patients with severe, chronic intractable pain proved effective for some patients who had failed conventional medical therapies.

Differences from conventional care

Because I continued to see patients in my old primary care clinic as well as at IMC, I had something of an informal 'controlled trial" to compare patient care.

Many of my patients saw me in both locations. They told me they enjoyed the more relaxed environment at IMC where patients are scheduled for 30-minute visits. They also liked the office design. IMC is new, with "healing" colors and excellent space planning. And some patients liked the computerized medical records that IMC keeps--however, most weren't impressed one way or the other but focused on the care they received.

The primary advantage my patients reported was the sense that all the disciplines were working together. Being able to walk across the hallway with a patient to discuss chiropractic or acupuncture for a symptom that wasn't responding to Western treatment had value. Patients liked having on-site herbal preparations both for convenience and for quality assurance of the products.

Generally, patient satisfaction was higher at IMC. However, some patients did not like the lack of insurance coverage and sought treatment at my old office where their insurance was accepted.

Much of what IMC is doing for patients expands the quality of patient care. The different therapies are important, but my impression is that the attitude of caring for the whole person is the most important aspect of IMC.

Putting it all together

As physician executives know all too well, great ideas like integrative care often require great skill to implement.

Clinical management, operations management and financial management must be aligned to provide health care for our patients in conventional health care.

Integrative medical clinics have at least the same, if not more, business challenges.

I reviewed other integrative medicine clinics--both private medical groups and institutional--and found dramatically higher rates of financial insolvency than other medical provider groups.

I have been unable to find data, but anecdotal evidence is that at least half of such ventures initially "fail" and require major re-organization or else they dissolve. IMC was no exception.

After eighteen months, IMC failed to meet any of its forecasted targets in volume, revenue or expenses. It failed to institute effective billing, collections and contracting. Being out of network, its market penetration was below projections. Its cost structure exceeded benchmarks. It is in the midst of a major re-organization. It must do this to stem losses of $50-100,000 per FTE provider/year.

Business imperatives

Root cause analyses of most failures reveals poor business leadership and management. IMC had no billing system in place when it started and few contracts. We discovered it was difficult to compete on cost with the cottage industry where complementary and alternative therapy providers frequently see patients in their own homes for $30-50 an hour.

Programs were developed without feasibility analysis and, overall, IMC had a poorly executed business plan. Had the management had to "sell" its idea to venture capitalists or to an astute board of trustees, many of the challenges would have been remedied before opening the doors.

Since it was personally financed by clinicians without any formal business or executive training, there was only naive enthusiasm on opening day and little advance business reality testing or preparedness.

For example, IMC could have known ahead of time that Medicare will pay for biofeedback, but only for urinary incontinence. Workers Compensation, Medicare, and many insurance policies pay for chiropractic, acupuncture and some other complementary and alternative care, especially using 'incident to" procedures. But, as with allopathic care, the issue is in the details of coding, documentation, billing and collections.

Critical success factors

This "market" integrative medicine is not for the business naive! Whether you are a GEO or VPMA in a multi-hospital system or a solo physician wanting to begin incorporating complementary and alternative therapy providers in your practice, you must start with the basics:

* A clear vision of what the organization or individual is trying to accomplish

* A sound business plan

* Excellent managers, clinicians and staff

* Financial management

* Marketing

* Operation controls in quality

Integrative medicine needs physician executives

As Kaiser said in The Physician Executive article, "Appropriate medicine is anything that's evidence-based and works."

The issue is not whether integrative medicine is appropriate or of better value from a cost and quality perspective. The question before physician executives is how do you do it?

I have no doubt that over the next 10 years all medical group providers will have reliable, credentialed, quality-driven integrative medicine programs and providers. We will understand the proper role of each type of care for disease states as well as prevention.

As importantly, we will understand better the relationships to the payers, suppliers, operations management, billing/collections, "incident to" and other "bottom line" imperatives to create sustainable value-added integrative medicine services for our patients and communities.

I left IMC a few months ago to work with other medical groups. I believe we are ethically required to foster integrative medicine in our medical organizations. It is the right thing to do (leadership), but we must do it right (management).

Walter Mills, MD, MMM, CPE is regional medical director of Fallon Clinic in Worcester, Mass. He can be reached by phone at [phone] or by e-mail at [e-mail]