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."

Minnesota-based Bolles has a unique resume in these fields. Beside various leadership roles in his own profession, he served as vice president for at the multidisciplinary Northwestern University of Health Sciences.  There he was instrumental in setting up the integrative clinic at Woodwinds Health Campus of the HealthEast system. He subsequently worked in a leadership capacity with UnitedHealthcare in developing their consumer information, website and strategy. Bolles is presently consulting in various capacities and is developing an initiative entitled Consumer Health Union. He is available at [email protected].

Marketplace: The Secret Sauce to Inject into the Trends
and into Integrative Business Models

Stephen Bolles, DC
[email protected]

Stephen Bolles, DC

Reading 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.

In a 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 Envy the 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 of gravity on how the trends play out."

Without 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.

To 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 career) viewpoint:

8. Physicians 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, we will be scrambling to develop stronger relationships with them than most of us currently pay attention to.

7. Emerging 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.

6. The 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. 

5. Comparative 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.

"Most of what passes for 'patient-centered' descriptors makes me want to gag--because it's the system's version of what patients want."

4. Most 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, not consumers'.

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 opportunity to refine how we use our emerging leadership roles in health care to help 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.

Anyway, 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 health professions.

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? 

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