Even when research finds that complementary and integrative medicine (CIM) or approaches are effective, these still may be shunned by health care's major stakeholders. Employers, private insurers and government agencies like Medicare that pay for services often block inclusion due to concerns about costs.
The findings of an exhaustive, systematic review of cost studies on complementary and integrative medicine from 2001-2010, published in the British Medical Journal Open, begins to provide definitive guidance. The report, led by Patricia Herman, M.S., N.D., Ph.D., will not immediately please every integrative health advocate. Nor will it serve as marching orders for every health care benefits decision maker.
Yet, according to Herman, the research sets a new baseline in our societal grappling with CIM's prospective cost value to health care systems. The headline conclusion was that the "the higher-quality studies indicate potential cost-effectiveness, and even cost savings across a number of CIM therapies and populations."
Herman, formerly with the University of Arizona and now with the RAND Corporation, is a unique player in the integrative health universe. She is a professional economist who is also physician-level clinician and an NIH-funded researcher. Herman has published and prepared presentations on the topic of cost-effectiveness multiple times in recent years, including co-authorship of a paper for the Institute of Medicine's 2009 Summit on Integrative Medicine and the Health of the Public.
In an interview for this blog, Herman stated: "I'm tired of this talk that there is no evidence for cost-effectiveness of complementary and integrative medicine. There is evidence. We need to move onto phase two and look at how transferable these findings are. We can take this evidence and run."
The publication, entitled "Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations," grew from a collaboration between Herman and one of her co-authors, Harvard's David Eisenberg, M.D., that commenced during preparation of a contracted paper for the 2009 IOM Summit. Their team's exhaustive search yielded 338 economic evaluations, 114 of which included comparison of both effectiveness and costs between groups.
The heart of the paper is a five-page chart detailing 28 studies the team found to be of a "similar or better quality to those (cost utility studies) published across all medicine." Ten of these showed some frank cost savings, "from at least one perspective," as Herman points out. The studies that found cost savings ranged from acupuncture for breech delivery and for low-back pain, to manual manipulation for neck pain, natural products for various conditions, and a study of the whole practice of naturopathic medicine for chronic low back pain.
The cost effectiveness found in the other studies was through a conventional method that measures the impact of interventions -- in these cases complementary and integrative modalities or providers -- on "quality-adjusted life years." Treatment in clinics of Oregon chiropractors, massage, Tai chi, Alexander technique, and numerous studies of adjunctive acupuncture treatment figured into these.
Herman is quick to note that it is the nature of cost studies that "they don't lead to easy conclusions like 'acupuncture is cost-effective.'" Rather, these represent the results of a specific treatment given in a specific time and place, compared to costs for usual care in that individual setting. Cost-effectiveness cannot be generalized. Herman clarifies: "What we have here are some useful directions for exploring potential transferability of cost savings."
Herman is right that it's time to shift the dialogue from roundhouse dismissal of potential cost-saving contributions from what she and the authors call "CIM" treatments and providers. The evidence is there for proactive exploration of potential cost savings.
Interestingly, and ironically, the report affirms the instincts of U.S. Senator Tom Harkin and his congressional colleagues in 1998 when they created the mandate for the new National institutes of Health National Center for Complementary and Alternative Medicine (NCCAM). They charged NCCAM to engage real world outcomes and the health services type of research that might yield cost and effectiveness data to help us understand the integration of CIM "into health care delivery systems in the United States."
The irony is that NCCAM has largely turned its back on this charge. Less than 1 percent of NCCAM grants funded outcomes studies and just about .025 percent examined costs, according to an internal study of the 2002-2006 years. While NCCAM's 2011-2015 strategic plan has a stated "real world" direction, exploration of cost-effectiveness remains negligible. Prioritizing the most helpful questions to Medicare, employers and insurers such as Congress recommended -- e.g., what are the cost and effectiveness outcomes when a given population is treated by a certain type of practitioner (acupuncturist, chiropractor, naturopathic doctor, massage therapists, licensed midwife, etc.)? -- still fails to make its way to the center of NCCAM's focus.
Who will lead this research? The new Patient Centered Outcomes Research Institute would seem to be an optimal host for such research. Yet the quasi-governmental agency's strategic plan only belatedly directly referenced complementary and integrative medicine. And Congress banned PCORI from cost reporting in order to overcome right-wing fears of "death panels."
All of which leads us to a blunt observation that leaps at one on reading this exhaustive review. Why are there just 28 high-quality studies, internationally, over a 10-year period, especially in this time of a cost crisis? What might we learn about a deeper health reform from hard examinations of the effectiveness and cost outcomes of the health-focused, whole person approaches of integrative practitioners on a series of populations with expensive chronic conditions?
If we are to leave all stones unturned in warding off what one health wonk has called a train wreck in slow motion, Congress, and we the people, might start by reminding NCCAM, and PCORI for that matter, to turn this stone over.
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