Assembling a panel of alternative practitioners is a critical process for any hospital or system trying to integrate unconventional healthcare into mainstream medicine.
Karen Hohenstein, who specializes in complementary and alternative medicine with the Chicago-based healthcare consulting firm Tiber Group, says finding the right providers can be difficult.
"They need to be locally established providers with the right credentials, but you also need a philosophical match," Hohenstein says. "You want experienced practitioners who can fit into the system. Also, it is not credentialing that hospitals are used to, for example, when they look for someone who can do a procedure or knows how to use a piece of equipment."
A growing number of states have specific education, testing and experience requirements for the licensing and certification of alternative-care providers.
According to John Weeks, editor of The Integrator, a complementary and alternative healthcare business newsletter, all states in 1999 licensed chiropractors, 34 licensed acupuncturists, 19 licensed massage therapists and only 11 licensed naturopaths. Several of these professional societies also offer credentialing services. But there is no national, standardized equivalent of the credentialing process that has been established for medical doctors.
"This is an issue we're all grappling with right now," says Jane Guiltinan, a naturopathic physician in Seattle. "The insurance companies are doing some of this, but we need dialogue with (the Joint Commission on Accreditation of Healthcare Organizations and the National Committee for Quality Assurance) in designing appropriate standards."
A similar challenge for alternative medicine integration exists in coding and billing standards for alternative treatments. Kenneth Pelletier, M.D., director of the Complementary and Alternative Medicine Program at Stanford University, says there are very few Current Procedural Terminology codes specific to alternative therapies.
"Without a dollar value, you can't bill for it," he says. There have been some health plans that have made forays into developing new codes, Pelletier says, but a definitive system will likely have to wait for broader medical acceptance of complementary and alternative medicine that hinges on more clinical evidence.
"What we have now is a coding and reimbursement system that is an (American Medical Association) proprietary system," says Keith Sarich, president of KMS Associates, a Valparaiso, Ind.-based healthcare consulting and alternative medicine recruiting firm. "It's like trying to mix apples with oranges. Sometimes it results in a darn-near fraudulent claim situation."
Concerns like these also have caused insurers to struggle with what are appropriate uses of alternative medicine.
Adela Basayne, immediate past president of the American Massage Therapy Association, cites a number of forces at play in determining coverage.
One is an any-willing-provider law, such as the Washington state model. That law, which was upheld by the Washington Supreme Court in January following a lengthy battle, is the only such law to require insurers to cover the services of every licensed or certified healthcare provider in the state (Feb. 7, p. 36). Other states are considering similar wide-ranging mandates, Basayne says, but more typically state laws require insurers to offer access to a network of practitioners who have agreed to provide certain treatments, such as massage therapy, at a discounted rate. Those services, however, aren't reimbursed. She adds that health plan members in these programs can't always be sure they're being offered discounts from reputable providers. And massage therapists aren't happy about the results: They get more business, but with a less profitable return.
On the other hand, massage therapy could be insurers' Exhibit A as the kind of therapy for which utilization is never-ending. It is, after all, used both for pain relief and for preventive care.
"So (insurers) are really asking us to provide protocols for standards of care," Basayne says. For example, for X condition, you should see improvement after Y number of visits. "What we are working on is creating standards of care that are outcome-based," she says.
James Dowden, M.D., executive director of the American Academy of Medical Acupuncture, a group of physicians licensed to practice acupuncture, says some insurers, notably HMOs, have argued in favor of nonphysician practitioners for services such as acupuncture to save on costs.
Dowden says some Blue Cross and Blue Shield plans will reimburse for 25% of some alternative medicine services, but no physician will accept that. "Many are using (alternative medicine) as a marketing ploy, in part because costs and losses are relatively benign," he says. "Many of our people would just as soon not have insurers involved. It's a little like plastic surgery, in the sense that they are getting paid cash right now."