Picture alternative medicine in the mainstream

Picture alternative medicine in the mainstream – includes related article

Janet Firshein

That’s where a wide variety of unusual therapies are headed, despite scarce evidence of how well they work. Are some benefits managers ahead of the curve — or off the deep end?

Fifteen years ago, Leslie Scallet’s neck had become so intractably stiff that she finally gave up on home remedies and sought medical treatment. Three doctors and $500 in medical bills later, there was little improvement and no definitive diagnosis. That’s when Scallet, executive director of the Washington think tank Mental Health Policy Resource Center, decided to try a therapeutic massage. After her first treatment, says Scallet, “the pain was gone.” She now spends $60 every month for a deep massage and calls it the “most effective thing I do to maintain my health.”

Scallet’s experience as a patient is increasingly common. A key Harvard University study published two years ago in the New England Journal of Medicine says that one out of three American adults used alternative medicine in 1990 to treat back pain, colds, and cancer, among other ailments. Indeed, the study found that the estimated number of visits — 425 million — to providers of unconventional therapies was nearly 10 percent greater than the number of visits to traditional primary-care doctors that year. And the patients paid most of the approximate $13.7 billion cost of the treatments themselves.

That out-of-pocket expense shifts the focus to Scallet’s experience as an employer who manages health benefits for 15 employees. Scallet says she has little flexibility to cover massage or other unconventional treatments for employees. Like millions of small employers, she feels lucky to find affordable coverage for even the basics. But she’d include massage if she could. Scallet and like-minded employers, however, have little data on the cost effectiveness of alternative treatments. That’s the major reason most employers ignore or resist alternative medicine despite growing interest and use. Research efforts have begun, though, and some employers are pressing forward with expanded coverage.


Alternative medicine encompasses mainstream therapies like chiropractic manipulation, relaxation techniques, massage, and acupuncture, as well as more offbeat practices like homeopathy, biofeedback, hypnosis, herbal medicine, traditional oriental medicine, chelation therapy, Ayurvedic medicine, and even crystal therapy. (See the primer on page 32.) Except for chiropractic and limited acupuncture coverage–mostly for pain and treatment for asthma–most employers are wary of integrating this wide array into their traditional benefit packages.

“Most employers are looking for ways to limit coverage, not to expand it,” says Scallet, whose group advocates wider use of behavioral therapy for chronic health problems. In today’s cost-conscious climate, she adds, “it would be difficult to bring alternative medicine forward as a serious proposal” until it attains more credibility.

Employers generally consider expanding benefits “if employees scream loud enough,” says Lawrence Jack, a chiropractor and associate medical director for MetraHealth in Atlanta, Ga. At New York-based AT&T, “there hasn’t been a hue and cry from employees” for alternative medicine, says spokesperson Burr Stinson. AT&T employs about 250,000 people, more than half of whom are union members. “Much of our benefits program is based on union leadership bringing us requests from members,” says Stinson. But “in a time when so many jobs are being phased out, expanding medical benefits is not a top priority.” AT&T does cover 60 chiropractic visits a year and limited psychotherapy treatment. The company also has been a leader in creating worksite wellness programs to help keep employees in good physical shape. “There was a time when our coverage didn’t get involved in any of that, so there might be a time when alternative medicine also gets included,” says Stinson.

The time has not come for San Francisco-based Levi Strauss & Co. Although an innovator in health coverage by offering health insurance to those of its 28,000 U.S. employees with domestic partners, Strauss is traditional in its health benefits. Corporate Communications Director Sean Fitzgerald says its policies are based on protocols recognized by the American Medical Association and “have not focused on herbal or experimental protocols.”

Chiropractic and acupuncture therapy are covered for the 17,000 employees of Southern California Edison in Rosemead, Calif. But before adding other alternative benefits, says Benefits Administration Manager Suzanne Mercure, “We need to know they don’t just add cost.” On that point, “employers are completely in the dark,” says Jessie Gruman, executive director of the Washington D.C.-based Center for the Advancement of Health, a pro-alternative consultant to insurance purchasers. “Ultimately, all of these interventions are going to have to show that they can reliably improve health outcomes, and not much can happen until there are more data,” Gruman says.


Some attempts have been made to fill the data gap. In 1992, the National Institutes of Health created the Office of Alternative Medicine. Although its $5 million budget is a pittance of the NIH’s $11 billion pie, OAM has wasted no time in getting to work.

OAM has spent nearly $1.7 million to support the creation of two research centers. One, at the University of Seattle, will explore alternative treatment of AIDS. Another, the Minnesota Medical Research Foundation, will evaluate alternative therapies for addiction disorders. OAM has also awarded 42 research grants of $30,000 each to American universities. Among the projects: acupuncture for easing pain from oral surgery; homeopathic treatment for mild brain injuries; traditional Chinese herbs for menopausal hot flashes and common warts; prayer intervention for substance abuse; yoga-breathing for obsessive-computsive disorders; biofeedback and relaxation for diabetes; and guided imagery for treatment of asthma.

Joe Jacobs, M.D., the first and former head of OAM and onetime medical director for Aetna Insurance, notes that NIH is also spending $12 million on alternative medicine research. The National Institute on Aging is testing whether t’ai chi can improve elderly movement disorders; the National Heart, Lung & Blood Institute is studying transcendental meditation’s effect on curbing heart attacks; and the National Institute on Drug Abuse is examining whether acupuncture can stem cravings for crack cocaine.

Boston’s Beth Israel Hospital added to the flow of information last month with a major continuing education course on alternative medicine for doctors, nurses, psychiatrists, medical educators, and managed-care executives. David Eisenberg, M.D., chief researcher in the landmark Harvard study and director of the course, notes that seven in 10 users of alternative therapy do not even discuss the practice with their primary care doctors.

On the corporate front, Jacobs is now working with the Washington Business Group on Health on a project to get employers more involved in the debate on alternative medicine. They have been “conspicuously absent,” says Miriam Jacobson, who directs the Prevention Leadership Forum at the WBGH. “We may be missing the boat on a vast universe of treatments” that are cost effective in keeping employees healthier.

The WBGH project offers a way for corporate leaders to explore whether alternative medicine can help them manage costs and improve quality for employees, dependents, and retirees. Besides defining exactly what constitutes alternative medicine therapies, Jacobson says health benefit decisionmakers need “a basic framework” to explore cost effectiveness and efficacy; to become knowledgeable about the prevalence of certain treatments, their costs, outcomes, and patterns of use; to develop an awareness of existing research and resources; and to look for examples of corporate best practices in the alternative medicine field. “It’s time to start quantifying these issues and putting them into language that corporate America can understand,” says Jacobson.


Even without significant data, some kinds of alternative medicine are gaining acceptance at the state and corporate levels. Forty-one states now require insurers to offer chiropractic coverage, and six (Calif., Fla., Mont., Nev., N.M., and Ore.) require insurers to offer the services of an acupuncturist, says the Blue Cross and Blue Shield Association. Alaska mandates coverage for naturopaths, and Florida mandates that health plans offering massage therapy cover any physician-prescribed services rendered by a state-licensed provider.

Still, much skepticism among employers and insurers stems from the lack of solid accreditation programs. “In many states, anyone can hang up a shingle that says ‘I am an herbalist.’ The groups of practitioners need to organize better,” says Steve Gorman of Alternative Health Insurance Services Inc. (AHIS) in Thousand Oaks, Calif. Atlanta chiropractor Jack concurs that licensure can elevate the status of alternative-medicine providers in the eyes of the business community, noting the current organized effort to get massage therapists accredited in and licensed by the state of Georgia.

Insisting that employees use only providers who are licensed by or registered with the state was a safeguard for Ben & Jerry’s Homemade Inc. in Waterbury, Vt., which has had an alternative-care benefit for its 550 employees since 1989. “Most alternative providers focus on preventive care, which we really like,” says Human Resources Manager Liz Lonergan. The plan covers naturopaths, herbalists, chiropractors, and acupuncturists.

For many multistate businesses, finding insurers that offer a network of alternative providers has been difficult. The National Nutritional Foods Association (NNFA) in Costa Mesa, California, offers its 5,000 health food retail store members nationwide an affordable group health package with alternative therapy benefits. Janet Cardillo, membership program coordinator, says the policy covers traditional doctors and alternative providers, such as naturopaths, acupuncturists, and Ayurvedic medicine. “For our industry, which is wellness-oriented, it is a perfect match,” says Cardillo.

To create the package, Cardillo turned to Gorman of AHIS, which he set up in 1985 to find alternative health plans for individuals and groups. Many AHIS clients are self-employed or independent contractors, but Gorman also works with the National Organization for Women, which includes chiropractic therapy and acupuncture in its benefits package, and a labor union in Chicago. The 4,000-member International Professional Craft & Maintenance Employees (IPCME) supplements its traditional benefits package with a comprehensive set of alternative benefits similar to what NNFA gets. The city of West Palm Beach, Fla., also has contacted Gorman and is looking at alternative benefits options for its 900 employees.

Gorman also has set up the country’s first national voluntary holistic purchasing coalition–the Alliance for Alternatives in Healthcare. This network of holistic providers of natural health products and services offers discounts to subscribers, which include IPCME, NNFA, New Age Publishing & Retailing Alliance, and the Natural Marketing Association. Gorman says the mission of the coalition will be to develop programs that promote natural healing and provide alternatives to traditional medical care.

Some traditional insurers have mounted their own initiatives in alternative care. Since 1993, Mutual of Omaha has covered patients in a pilot program designed by diet guru and best-selling author Dean Omish, M.D., to reverse heart problems without drugs or surgery. Ornish, who directs the Preventive Medicine Research Institute in Sausalito Calif., champions low-fat diets, exercise, yoga, meditation, and support groups. For a $5,000 enrollment fee, he argues, insurers can avoid paying about $43,000 for bypass surgery costs or $18,000 for angioplasty. The project has enrolled 189 patients and is being tested in four hospital sites across the U.S.

American Western Life Insurance in Foster City, Calif., has signed up as many as 3,000 subscribers in Arizona, California, Colorado, New Mexico, and Utah, in its two-year-old Wellness Plan. “While many of these remedies have been around for hundreds of years, Westerners are finally catching onto them and discovering that they really work,” says AWLI President Leland Wolf.

This year, AWLI will extend its alternative medicine package to Oregon and is considering the Michigan market. The Wellness Plan includes coverage for traditional medical care and visits to a network of holistic providers. AWLI also offers a 24-hour toll-free hotline for all subscribers, staffed by holistic-oriented doctors who promote self-care and natural care at home for mild conditions.

Companies that subscribe to the Wellness Plan are mostly smaller businesses that are paying attention to employee demands, says marketing assistant Jenny Schreiber. She expects larger companies to become more interested as the plan spreads nationally and demonstrates savings. AWLI estimates that alternative benefits cost 15 percent to 20 percent less in premiums than traditional plans. A recent AWLI analysis estimates that the Wellness hotline yielded as much as $250,000 in savings last year by exchanging doctor visits for self-care at home.

Last May, Blue Cross of Washington and Alaska launched a pilot alternative care program that will cover services of 13 homeopathic and naturopathic physicians and acupuncturists in the Seattle area. The Alternpath Nontraditional Health Care Program filled its 1,000 subscriber slots in three months. Jennifer Rief, public affairs administrator, says the Blues set up Alternpath in response to subscriber requests expressed during town meetings on health reform conducted in the state in 1993. “They were saying to us, ‘We need alternative care as value added on top of what we have,'” Rief explains. The pilot will last until September 1995 and is expected to build a base of data on enrollee utilization, provider practice patterns, and costs. If successful, it could be expanded to a larger group of patients and practitioners in Washington. Blues plans in Arizona, Hawaii, and Ohio are considering similar initiatives.

Although corporate America’s acceptance of alternative therapy will take time, Center for the Advancement of Health’s Gruman is not discouraged. In attempting to respond to employer demands, managed-care firms “are going to be looking for ways to improve health outcomes at lower costs, and alternative medicine intervention occasionally has been shown to do that,” Gruman says. The emphasis on wellness in many alternative care systems could prove to be an advantage. “Employers want services that will give them a healthy workforce,” argues Gruman. “Under capitated care, even more of them will be saying, ‘We want plans that reduce the days lost from work, get people back to work in better shape, and lower disability costs.’ I think that offers an opportunity.”

Janet Firshein, a 1994 Kaiser Media Fellow, writes frequently about health care. She lives in Washington, D.C.

A Primer on Alternative Care

Chiropractic is by far the most common alternative therapy. It is based on the theory that disease results from the lack of normal nerve function and can be cured by manipulation of the spine. Most patients are seeking relief from back or joint pain. Other structural and energetic therapies are used to stimulate or relax muscles. They include such massage techniques as rolfing, which purports to restore the body’s natural alignment, and the Alexander technique, which teaches people to stand, sit, and move with less tension.

Traditional Chinese medicine is the source of many well-known alternatives. Its practices center on the belief that a universal life force called chi manifests itself in the body in two complementary qualities: the energetic, assertive yang and the restraining yin. Imbalance between yin and yang and disruptions in the flow of chi are said to be the cause of ill health. A variety of therapies are intended to restore or facilitate the flow of chi. In acupuncture, the therapist inserts needles at specific points along the meridians, or channels, of the flow. Acupressure is a variation that uses pressure instead of needles. T’ai chi is an exercise of slow, continuous movement through a series of more than 100 postures. Herbs also play a significant role in Chinese medicine.

Similar themes are found in other ethnic medicines. Herbal treatments, for instance, are used often in Ayurvedic medicine, which has been practiced in India for thousands of years. Ayurveda also relies on mind and body therapies, such as massage and yoga. The idea of a balance between forces–specifically good and evil spirits–is central to Shamanism, which is practiced among Native Americans.

Less ancient alternatives include naturopathy, which is based on the idea that disease is caused by accumulation of waste products and toxins in the body. Practitioners try to avoid anything unnatural or artificial in their diet or environment. Elimination of waste to restore tissue and organ function is the goal of colon therapy.

Diet and nutrition are frequent concerns in alternative therapies. Vitamin supplements, sometimes in massive doses, are common, as are antioxidizing agents that theoretically counter the effects of dietary fat.

Chelation therapy uses chemicals that combine with toxins in the blood stream so that they are excreted more rapidly. Homeopathy uses tiny doses of minerals and substances to produce symptoms of an illness. The theory is that “like cures like,” and the induced symptoms will immunize the patient.

Mind/body control techniques are aimed at helping patients achieve a state of relaxation. They are frequently used to relieve intractable pain, such as from migraines or cancer. Practices include meditation and guided imagery. Biofeedback attempts to train people to control involuntary functions such as heartbeat. Art, music, and humor therapy make organized use of these common tools to help chronically or terminally ill patients. Aromatherapy is said to be particularly effective for stress-related disorders. Practiced in many ancient cultures and used widely in Europe, the technique employs small quantities of fragrant oil that are applied in massage or inhaled.

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