Testimony before the Vermont House Health Committee
3/10/05
Witness: Dr. Laura Patton, M.D.
Clinical Director of Alternative Services
Group Health Cooperative Managed Care Organization, WashingtonState
Dr. Patton: I’ll dive right in and make a short statement, and then you folks can ask me questions.
My background: I’m a board certified family physician with 23 years of practice experience. For the past 9 years I have been the Clinical Director of Alternative Services at Group Health Cooperative, which is a managed care organization which provides comprehensive medical services to approximately 600,000 members in WashingtonState and northern Idaho. We’re the third largest health plan in the state.
We have had a program of access to - for a lack of a better word - alternative services since 1996 which resulted from legislation which was passed in 1995, which became known as the “Every Category of Provider Legislation.” Basically, what this required, was that all health plans in the State of Washington cover the services of all categories of licensed providers within the scope of their practice.
On the other side, the providers agreed, and I’m going to quote from the language of this mandate, “the providers agree to abide by standards related to provisions of cost-effective and clinically efficacious health services, and further agree to standards related to utilization review and cost containment.” It was quite vaguely worded, and left the health plans quite confused as to how to go about implementing this.
In our case, as a managed care organization, we chose to implement it, and offer these services in a similar way that we do with conventional medical services. And I should clarify that licensed providers in the state of Washington subject to this mandate include acupuncturists, massage therapists, naturopathic physicians and chiropractors. I know that licensing varies a lot from state to state.
There were several legal challenges to the law, a lot because of the vagueness of the wording, which kept lawyers busy for a number of years. The concerns among the health plans are the same kind of concerns that you’re hearing about in Vermont. There’s a big concern about the possibility of increasing the cost of health care in a setting where health care costs are already going upward at a fairly alarming rate. There are concerns about quality of care, which, when you scratch the surface, often boil down to ‘we don’t even know what these providers do, so how can we intelligently offer their services?’ There are some liability concerns as well.
Well here’s how we approached this at Group Health. You’re going hear me use the acronym CAM, which is Complementary and Alternative Medicine. I don’t know if you folks are familiar with that. In order to effectively monitor care and utilization, we elected to contract with a limited number of CAM providers. Currently our network consists of about 800 providers, 91 of whom are licensing naturopathic physicians. We also decided to delegate credentialing to a third party organization, American Whole Health Network, who had experience in this area.
To begin with, access to all CAM services, except chiropractic, required a referral from a Group Heath physician, and this is similar to how we had structured it on the conventional side as well. That was one of our goals: to manage it similar to how we manage care on the conventional side. In addition, we reviewed additional evidence of efficacy as well as we could, and engaged in discussions with local leaders in each of the CAM professions.
From these activities, we generated a list of conditions specific to each CAM profession for which we would allow referrals. For example, for naturopathy, we cover referrals for many common chronic conditions such as fibromyalgia, menopause and chronic fatigue, but did not cover acute conditions, such as respiratory tract or injuries.
The point I’m making here is that in the beginning, nine years ago, access to CAM services was pretty tightly controlled. As we’ve progressed over the past nine years, we have loosened those controls considerably because our experience has been quite positive.
I’ll give you some of our major learnings. Utilization has been much less than we feared. Based on local and national surveys, we were anticipating up to 30% of our enrollees would utilize CAM Services overall. And the real numbers have been much less. There’s a group at the University of Washington that has collected data from the three major health insurers in WashingtonState and is analyzing that now, and I think Dr. Noe has some of their preliminary cost information.
Chiropractic, as is true nationally, is by far the most commonly utilized, with somewhere between 8-10% of our population using it in a given year, followed by acupuncture and massage, and then naturopathy, which has actually been consistently less than 1% of our insured population. And this is in an area where naturopathy is pretty well known.
Because of our great experience in utilization, and frankly, in terms of our good experience with the providers themselves, and also because Group Health was moving in this direction, in January of 2003, we started to allow self-referral for our naturopathic services as well as acupuncture services. In spite of the lifting of restrictions, utilization has not increased significantly. In was just looking at numbers from 2004, and our claims costs went up only 3% compared to 2003, and this is consistent with the small increases that we’ve been seeing from year to year.
Anyway, so our experience, particularly with contracted naturopathic physicians has been very positive. Because of their training compared to other CAM providers, the naturopathic physicians have been much quicker to understand our needs with respect to coordination of care and documentation, as well as nitty-gritty things like coding and billing. The average number of visits per patient has consistently been between 2 and 3 per episode of care. There have been no litigation issues.
Group Health physicians have expressed appreciation for the skill set unique to naturopathic physicians, and are quite happy actually to have them as a resource to offer patients with chronic problems which are not responding to conventional interventions.
Patient satisfaction has been extremely high. We do patient satisfaction surveys every year. We wish that we got such high numbers on the conventional side as we do with patients who utilize CAM services. Generally, 90 to 95% of the patients surveyed will express satisfaction to extreme satisfaction with the care that they have received. And 92% report improvement in the problem for which they sought care.
Specifically, with respect to this issue of are their cost offsets on the conventional side, we asked patients in the survey to tell us their perceptions of whether their use of conventional care decreased as a result of their care that they received from CAM providers. With respect to naturopathy-I’m looking at a survey from a couple of years ago—59% of them reported decreased visits to primary care physicians, and about 48% reported decreased visits to specialists. And then another major driver of health care costs, over 50% reported decreased use of prescription medications. So I can’t give you this hard and fast evidence that there are cost benefits. For one thing, the utilization in our system has been small enough, and our information systems are not sophisticated enough to be able to tell that, but I think the net impact in terms of costs, certainly in direct claims costs has been quite minimal.
So I guess in summary, what I’d like to say to you, that based on our nine years of experience, including the services of naturopathic physicians can be done with minimal impact on costs, with oversights similar to that which applies to conventionally trained health care professionals, and will definitely contribute significantly to patient satisfaction in the segment of the population who is inclined to use these services. So with that, I’m happy to answer questions.
Rep. Steve Maier: “You mentioned that in the beginning, you only, I think, reimbursed for certain chronic things like fibromyalgia, and that now, as of a couple of years ago, you are allowing self-referrals. Have you also expended the things that you cover to the entire scope of practice for naturopathic physicians?”
Dr. Patton: Yes. The self-referral benefit allow patients to see naturopathic physicians for any condition.
Rep. Maier: That they’re licensed to provide?
Dr. Patton: Exactly. Now I will say, that because of our managed care company, that we ask, after two visits, for a treatment summary, so that we have some idea of what type of care is being provided. That’s because one of our goals here at Group Health is to coordinate care. So we do ask for that. But otherwise, patients can be seen for any condition.
Rep. Milkey: If you still have that language handy that says ‘agrees to abide by standards related to…” could you run that by me?
Dr. Patton: Yes. Let me get that here. I can read you the entire language of the law, but what I read to you, is that “providers agree to abide by standards related to provision, utilization review and cost-containment of health services.” And then further “the provision of cost effective and clinically efficacious health services.”
Rep. Milkey: Thank you.
Rep. Mc Faun: In your discussion, you talked about the acupuncturists, the naturopath; you didn’t talk much about chiropractic. Is there a reason for that?
Dr. Patton: Right, because the hearing’s about naturopaths. But chiropractors have been more of an integral part of our delivery system for a longer period of time, although they were not part of our base benefit until the state mandate. It was offered as a rider, and was a very popular rider, to the extent that we already had a contracted network of chiropractic doctors at the time that the mandate became effective. And their utilization was so stable that we elected to reimburse them on a capitation basis. That arrangement has continued to the present day. So it’s a little bit different, but we are quite satisfied with our experience with them as well.
Rep. Chen: In your system, each one of your members has a primary care provider—is that correct?
Dr. Patton: Yes.
Rep. Chen: Do your naturopaths fulfill that role?
Dr. Patton: No, not in our system. We elected to use them more as consultants. Now that’s different from the two other major insurers in our state. The Blue Cross plan, which is called Primera, and the Blue Shield plan, which is called Regents, both allow naturopathic physicians to function as primary care providers.
Rep. Chen: Can you give me any insight as to why you made that decision?
Dr. Patton: Well, it’s a little complicated. Being a managed care organization, we have, I guess the core of our business is what we now call “Integrated Group Practice”. It used to be called a staff model HMO. And so, in the greater Puget Sound area, the vast majority of Group Health practitioners are on salary. We also have an extended PPO network in most of the counties of the state. One of the---the way we deliver care is strongly primary care oriented too, that’s why all of our members do pick a primary care physician as their coordinator of care. So given that naturopathic physicians don’t have exactly the same skill set as what we generally require of primary care physicians within our system, and given that there are frankly, not that many of them, it didn’t work—we couldn’t figure out a way to incorporate them in the same way in our deliver system.
Chairman Tracy: Are there any other questions? Dr. Patton, thank you very much.