Alternative Medicine: Separating the Wheat From the Chaff

Times change; the pendulum swings. Once, not so many years ago,mainstream health providers and insurers viewed all alternativeand complementary practitioners as quacks.

In less than 10 years, the pendulum reversed direction. Today'salternative and complementary practitioners not only treat patientsinsured by leading managed care organizations, but also serveas gatekeepers, directing patients to specialists, or not, accordingto their understanding of clinical status.

The growing popularity of alternative and complementary practitionersis based, at least in part, on their tendency to spend more timewith patients and, typically, to reflect a sense of caring. Patientsmay find this missing in mainstream medicine, particularly inspecialty practices such as oncology.

Patients see alternative practitioners as being more like thefamily doctor of 50 years ago, the physician who knew and caredabout people in a pre-high tech, prespecialization era. The sensethat the practitioner cares is often more important to patientsthan the practitioner's technical skills or equipment.

We may view this as an unsound basis on which to make health caredecisions. But the actions of patients in large numbers indicatethat they disagree.

The perceived differences between types of practitioners appearsufficient to motivate patient decisions and help explain thebusy family practice office of naturopaths, chiropractors, andother non-MD therapists who offer alternative, first-line healthcare.

Legislating Coverage

In early 1996, Washington state enacted "ECG" legislationrequiring health insurers and managed care organizations to recognize"Every Category of Provider." This means that treatmentby an ACR, CBPM, ND, CTP, OMD, or CA,* as well as many other unusually-initialedlicensed practitioners will be covered by insurance plans operatingin Washington state.

Acupuncture is a required coverage in at least six states, and41 states mandate insurance coverage for chiropractic care. Theserepresent good examples of therapies on the cusp--approaches thatwhen used for proven purposes can be helpful and are properlycategorized as complementary and mainstream. However, when appliedin efforts to cure disease such as cancer, as occasionally happens,they are considered alternative and unwarranted.

Unproven methods applied toward cure of cancer and other diseasesalso loom as potentially harmful, either directly or because theypostpone prompt receipt of needed therapy. Herein lurks a majorproblem with the merger of alternative medicine and cost-consciousmanaged care.

Will managed care organizations, in their continuing search formore cost-effective strategies, accept scientifically unacceptablealternatives such as homeopathic medicine? Will homeopathic remedies,which are generally free of side effects since they contain onlya molecule of active ingredient, come to serve a legitimate roleas placebos? That may be conscionable for the vast majority ofpatient visits based on self-limiting problems, but certainlynot in oncology.

The increasingly common use by managed care organizations of alternativeand complementary medicine raises striking quality of care issues.Anecdotal-based therapies, however soothing and popular, are nosubstitute for mainstream oncologic interventions. Alternativeor undertrained practitioners, no matter how comforting to patientsand cost efficient, cannot provide cancer care in lieu of trainedoncologists. Such trade-offs court disaster.

On the other hand, complementary therapies can be helpful as wellas economic additions to mainstream medicine if used appropriately.Various massage, exercise, and relaxation techniques; supportgroups; music therapy; acupuncture to relieve pain and nausea;and even aroma therapy and many other approaches have a legitimateplace as adjuncts to mainstream cancer care.

Managed care, or any other system eager not to lose its patients,understands the importance of patient comfort and satisfaction.In this respect, investment in appropriately applied complementarymedicine will pay off.

The challenge to managed care organizations, as they work to reducecosts and generate profits, is to separate the wheat from thechaff.

Those who manage the managed care organizations must master thecrucial differences between "alternative" therapies(typically unproven approaches aimed at cure) and "complementary"therapies (adjunctive measures applied for symptom control orenhanced well-being), and create policies that enable patientsto receive inherent benefits while providing solid protectionagainst potential dangers.

Dr. Cassileth is adjunct professor of medicine oncology, Universityof North Carolina at Chapel Hill, and consulting professor, Communityand Family Medicine, Duke University, Durham, NC. Dr. Bennettis senior research associate, Lakeside VA Medical Center, andassociate professor of medicine, Northwestern University, Chicago.

SIDEBAR

Insurers Open the Door to Alternative Medicine

In 1994, Blue Cross of Washington and Alaska launched Alterna-Path,becoming one of the first insurers to recognize naturopaths, acupuncturists,and other alternative medicine practitioners.

American Western Life Insurance markets a "Wellness Plan"that recognizes many types of unconventional providers. It promotesa 24-hour holistic hotline and offers a patient handbook describing"natural" remedies for common maladies.

At least one HMO on the East Coast--the Oxford Health Plan--dedicatesan entire division to integrating alternative and complementarytherapies.

Griffin Health Services Corporation in Connecticut has developedprograms to amalgamate primary care, a wellness center, and alternativepractitioners.

American Medical Security is a leader in marketing alternativeoriented health plans nationally.