DR. MARION: My name is Phil Marion. I am a medical director of rehab medicine at The George Washington University, up the street. A question for Dr. Eisenberg and perhaps an observation.

I am one of those allopathic physicians, who is also a medical acupuncturist, and I have noticed that patients, who come in; are not insured; and are going to pay cash, have a different enthusiasm, if you will, toward the treatment of acupuncture than someone who receives it from their managed care companies.

As a matter of fact, patients are a bit suspect if they are going to be covered by their managed care companies, and sometimes that has an effect on the results of their treatment.

The second point I wanted to make was that very often with patients, especially if you look at stakeholders for patients covered by their insurance companies, they try to fit an eastern traditional medicine into western medicine. For example, they will give you four visits and they will say, get them better in three months or they have to get another referral. You then have to fight the battle with the insurance company, if you will.

In many ways, it turns out that having them covered by their insurance company is actually a detriment to their actual treatment. I am using acupuncture as an example, but for others as well, and I wanted your comments and experience on that.

DR. EISENBERG: I think these are excellent points. There is a large literature, much of it out of RAND, looking at how patients perceive and behave in health systems where health care is free, partially covered, or self paid, and I think that translates across the modalities used.

It is clearly a very important aspect of care, as to whether (a) you choose it, (b) you have access to it, and (c) how much you pay for it.

In the same way, trying to do a randomized trial of people who have an injury and are seeking worker’s compensation is very different from a population trying to get its life back and is very motivated to participate and pay any amount just to salvage a life.

I think these are factors that can and are being incorporated into some of the health service research. In all the studies I mentioned, these are some of the variables that need to be tested, not just the choice of a therapy, but the co-payment and the percentage of co-payment. I think these are part of the future of health service research in this area and your points are very well taken. Thank you.

DR. BULGER: I want to thank everybody. I will have an interesting e-mail for our members based on what we have learned tonight.

I heard from Cathie Woteki that we all need to explore the financial records of Osama Bin Laden and see whether he is in the herbal supplying

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