Managed care moves toward holistic approach
January 1, 1997
Managed care moves toward holistic approach
Blend conventional and alternative therapies
Managed care organization (MCO) members aren’t happy with their health benefits. They have launched a consumer rebellion gaining strength nationwide and demanding more coverage for alternative therapies such as acupuncture and chiropractic. (For more information about consumer demand for alternative therapies, see story, p. 18.)
HealthPartners Health Plans in Phoenix once only provided alternative therapy benefits to members in active case management. However, increased member demand and also positive clinical outcomes led the MCO to provide coverage for a wide range of alternative therapies to all its members.
"We contracted with the Arizona Center for Health and Medicine in Phoenix, which offers a range of modalities, including herbal medicine, acupuncture, guided imagery, and homeopathy," says Mary E. Mink, RN, BSN, a case manager with HealthPartners. "Our members can self-refer to the center for one course of treatment each year. We even cover the costs of herbal medicines."
However, HealthPartners members cannot receive more than one complete course of treatment each year, Mink notes. "If a member has an ongoing health problem, we feel that they need teaching and guidance to handle it and they must receive approval for further treatment from a case manager."
Other MCOs use alternative providers as their primary care model. "I prefer to use the term appropriate medicine, rather than alternative medicine," says Mary L. Fedak, director of provider relations for the Wellness Health Plans Provider Group managed by American Western Life Insurance in San Mateo, CA. "The way we look at things here: All things are medicine. You start with the least invasive therapy and move up the ladder as it becomes appropriate. At the far end, is the most invasive form of medicine, or conventional medicine."
"When it comes to handling trauma, surgery, or diagnostics conventional Western medicine is better than no other in the world. But it is less effective in managing chronic illness, supporting the immune system, and prevention. I think we need to offer members a blend of conventional and alterative therapies that produce the most appropriate combination for a given patient at a given time," Fedak explains.
Naturopaths provide much of the primary care received by Wellness Health Plan members, says Fedak. "Naturopaths go through much of the same training as MDs, including rigorous training in pharmacology. They use a whole range of therapies that support the body to maintain overall health and support the immune system. It’s a proactive rather than a reactive approach to health care, and naturopaths work well in conjunction with conventional medicine, when necessary," she adds. (More information about alterative providers and how to find them is detailed on pp. 20-21.) "For example, naturopaths have protocols to help cancer patients tolerate chemotherapy," she says.
Success stories
Most case managers have at least one story to tell about a patient whose chronic health problem was successfully treated by an alternative provider. "I had one patient with severe food allergies. She went to numerous allergists in the Phoenix-area, but no one was able to help her. She suffered from skin outbreaks, weakness and fatigue, and nausea and vomiting," says Fink. "She went to a homeopath, and she later told me that her skin cleared up, her energy returned, and she was able to return to work. She’s still doing very well," she adds.
Fink notes that alternative providers are also very effective at helping patients manage chronic and post-surgical pain. "I had a patient tell me that he hadn’t been able to sleep for six months after cardiac surgery due to the pain in his sternum, and his surgeon was unable to help him manage the pain. He went to an acupuncturist and now reports no pain or discomfort," she says.
However, alternative therapies are not without risk, and they aren’t "magic bullets" that achieve overnight results, cautions Fedak. "Alternative therapies require that patients take responsibility for their own care. Alternative therapies also require longer courses of treatment and strong patient commitment to compliance," she notes.
Must have patient commitment
"Without patient commitment, you won’t have the compliance you need to achieve success with alternative therapies," agrees Susanne R. Hays, RN, MS, CRRN, president of Adaptations, a case management specialty company in Albuquerque, NM. "Patients can’t just go to an acupuncturist. They have to look at themselves, and their personalities, and see if an alternative provider is a good choice for them."
Questions that Hays suggests case managers ask patients considering an alternative provider include:
• How internally focused are you?
• How willing are you to make lifestyle changes?
• Do you believe in a mind/body/spirit connection?
Success depends on the patient
And even more so than with a conventional provider, patients must be comfortable with an alternative provider to have a successful outcome, stress Hays and Fedak. "Patients must shop around, ask questions, and refuse to go blindly along with a treatment plan, if they are not completely comfortable with a provider. They must not assume that any one therapy is good for everyone, or that all alternative providers are good people," says Fedak, adding that many alternative therapies lack a credentialing standard.
Patients who have been under the care of a primary care physician for a chronic health problem, must also be careful not to embrace an alternative therapy so completely that "they throw their medicine down the drain," cautions Hays. "It’s very important for patients to find physicians and alternative providers who are comfortable working together until such time as the patient may be able to be weaned off prescription drugs. The lines of communication must be kept open, and the case manager can help keep that communication flowing," she says.
Hays once worked with a family whose newborn was hospitalized with a cleft palate and other health problems, including extreme drowsiness and feeding difficulties. "The family wanted to get the baby home and consult with alternative therapists that they knew well and trusted. However, the hospital would not discharge the baby until the family learned how to tube feed her," she notes.
Family learns proper care for their infant
Hays acted as an intermediary to get both sides to take a step toward the other. She explained to the family that the hospital would not discharge the infant until they learned how to tube feed her. Hays urged them to receive the tube feeding training even if they did not need it. She then approached the physician and urged him to trust the family and ask some specific questions which might help him better understand the infant’s health problems and the family’s feelings about her care.
"I was trying to build a bridge between the two sides. The doctor seemed prejudiced against the mother because the baby had been born at home, and now the family wanted to consult with alternative therapists,’ explains Hays. "The doctor really believed that the infant’s health problems might be linked to poor prenatal care, or even maternal use of alternative therapies, but that wasn’t the case. After talking with the mother, the doctor realized she had done everything right during the prenatal period."
The family learned how to do the tube feeding and the baby was released from the hospital, says Hays. The baby’s feeding problems were resolved with interventions from Hays who is a pediatric rehabilitation specialist. "The baby’s drowsiness was resolved by using remedies received from a homeopath. The mother never did tube feed the baby at home," she adds.
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