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2 The Vision for Integrative Health and Medicine An ounce of prevention is worth a pound of cure. —Benjamin Franklin Against the backdrop of Ralph Snyderman’s opening description of his vision for a more integrated health care system, a panel of national health care leaders offered their visions of the key dimensions of integra- tive medicine. Moderated by Michael Johns, the panelists emphasized the notion that the current health care system is fragmented, short sighted, and not oriented to health promotion or disease prevention, and that a shift in the focus of the system will be necessary for a healthy population. Bill Novelli, for example, described the large contribution that Americans’ individual behavior choices make in preserving health or causing diseases. Yet, the health system is not currently geared toward supporting individuals through the long and difficult behavior change process. The health system might be more successful in eliciting behav- ior change if it were supported by policy changes, coordinated action across social sectors, community-based efforts, and more robust and di- verse patient-education efforts, as described by Dr. Mehmet Oz. Dr. Vic- tor Sierpina also noted that clinicians will need a different kind of education to work in a more integrative and community-based way. Panelists discussed options for more integrative care efforts, includ- ing multidisciplinary care teams. Such efforts can be greatly enhanced by electronic data systems that provide comprehensive patient-centered in- formation to caregivers in a timely way, George Halvorson said. These systems could be the underpinning of a system for more patient-centered care. Ellen Stovall emphasized that clinicians must recognize that many of the skills patients need to actively participate in decision making about their care evaporate in the face of a serious illness, necessitating a greater measure of commitment by their clinicians and caregivers. 37

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38 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC PANEL ON THE VISION FOR INTEGRATIVE MEDICINE Panel Introduction Michael M. E. Johns, Emory University Dr. Johns began the vision panel with a brief review of life expec- tancy and causes of death. Each year, heart disease causes one death out of every five, and cancer, one out of every seven. While death is a cer- tainty for everyone, life expectancy and cause of death vary greatly due to individual risk and exposure. Not surprisingly, much of today’s health care system focuses on treating the major, often fatal, diseases. However, these efforts are not sufficient to achieve a healthy population, said Johns. What the health system should seek to accomplish is demonstrated by the “square wave life curve” (Figure 2-1). This curve is the ideal life- span experience—from birth, through a long, healthy life, and then a rapid decline and death at age 120 (in this illustration). The longest con- firmed life span in history was that of Jeanne Calment, of Arles, France, who died at age 122. She lived a remarkably healthy and active life for 100% Health status 0% Projected human life span Birth 120 years FIGURE 2-1 The square wave life curve.

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39 THE VISION FOR INTEGRATIVE HEALTH AND MEDICINE nearly that entire period; in a sense, she lived the square life curve. To achieve this ideal, the health system would have to concentrate more on wellness, health, prevention, and just plain living, bringing these factors into balance with the attention currently paid to diagnosing and treating disease. Johns noted that this concept of lifelong health could transform health care and would serve humanity well. Johns encouraged a reconsideration of some of the common terms used to describe our current health care system, in order to better align the terms with the envisioned health care system of the future. He noted that the term medical, as in medical care, often excludes the many other health-related professions. To improve the nomenclature, he would re- place evidence-based medicine with evidence-based health care, medical home with health home, and integrative medicine with integrative health and health care. Health Promotion and Disease Prevention William D. Novelli, AARP Successful health care reform and implementation of an integrative health model will require an increased emphasis on health promotion and disease prevention. Research by the National Business Group on Health indicates that, in 2000, almost 47 percent of U.S. deaths were caused by modifiable health behavior, including tobacco use, poor diet, and physi- cal inactivity (National Business Group on Health, 2007). These types of behavior are strong risk factors in all three leading causes of death: heart disease, cancer, and stroke. A coherent set of national health goals and strategies and an effective program for health promotion and disease pre- vention could provide one of the biggest returns on investment this na- tion could ever make, said Novelli. Substantial changes in health behavior would require a synergistic combination of social marketing and public policy strategies that reach beyond the clinical setting. Broad changes would be required in the envi- ronments in which people actually work, live, and play. These places include supermarkets, convenience stores, classrooms, playgrounds, fac- tories, and especially couches, where people are influenced by a barrage of media messages from television, video games, movies, computers, cell phones, and personal digital assistants (PDAs). These places are where

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40 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC behavior is set, where habits are formed, and where peer and other influ- ences take place; they are also where healthy behavior must become normative. To counter these influences, marketing programs and policy changes can encourage people to take the steps that will lead to good health. An IOM report, Ending the Tobacco Problem: A Blueprint for the Nation (2007a), for example, recommended combined marketing and policy strategies to reduce the use of tobacco. The policy changes included fed- eral regulation of manufacturing, marketing, and sales of tobacco prod- ucts; tax increases; and local interventions. The social marketing strategies recommended would combine with public policy and medical strategies to create more effective smoking cessation programs that go beyond the typical medical model. Although much of the discussion around prevention focuses on whether it adds to or reduces health care costs, the point of prevention is to maximize Americans’ health potential. It will take national leadership to refocus the health system on the problems and costs of preventable conditions. While government programs are important, the nation will also need true public-private partnerships. These partnerships must in- clude not just traditional health and medical entities but other relevant stakeholders—from educators, policy makers, insurance companies, drug manufacturers, and the news media to corporations, including the fast food and processed food industries, and those who influence our agricul- tural subsidies. Novelli said that the nation has been shortsighted in not supporting wider use of clinical preventive services (screenings, immuniza- tions, guidance on preventive actions); public, patient, and physician education programs on important risk factors such as hypertension; and successful public campaigns such as youth tobacco control initia- tives. Novelli said that the government also must redress the fragmentation of its current prevention efforts, which involve numerous federal and state agencies and produce little coherence, no synergy, and no “home- run power.” A more coherent approach across agencies and clearer prevention targets might help solve one of the field’s biggest challenges: We often know what to do, but we are not very good at getting people to do it.

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41 THE VISION FOR INTEGRATIVE HEALTH AND MEDICINE Integrative Infrastructure and Systems George Halvorson, Kaiser Permanente According to George Halvorson, one of the keys to advancing inte- grative health will be to develop a toolkit of relevant systems, infrastruc- ture, and support. Integrative health care not only requires patient- centered services, but also patient-centered data systems and information, as shown in Figure 2-2. By putting the patient at the center of health care transactions, health care providers can begin to overcome the silos within both specialty-based medical care and the various disciplines involved in alternative care. In a patient-centered data system, every patient is a data point from which much can be learned. Ideally, electronic data systems and health records would make pa- tient information available to every relevant caregiver in real time, which encourages and enables service integration, said Halvorson. The Ameri- can Recovery and Reinvestment Act of 2009 included support for elec- tronic patient records and electronic support for care, which could move this effort forward. However, the emphasis must be on information sys- tems that link with one another and share data across geography and pro- viders. New systems must not be allowed to simply replicate the problems inherent in the old, isolated paper medical records. Test results to patients Caregiver to caregiver Data to payer Data to algorithms Data to doctor Data to patient E-visits Data to consults E-scheduling • Patient record • Laboratory • EMR • Diagnostic imagery • Care registries • Pharmacy • Protocols • Care tools • Scientific studies • Population data Doctor to Images to caregivers doctor In-home monitoring E-enrollment Test results to caregivers FIGURE 2-2 Care that revolves around you. NOTES: Comprehensive data connections to every part of the system: all the info, about all of the patients, all of the time.

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42 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC The infrastructure for truly integrated care will also require health professionals to work more effectively in teams. These teams can include a variety of caregivers—nurses, physicians, primary care providers, spe- cialists, pharmacists, and alternative practitioners. These teams should be capable of effectively reacting to medical incidents, but also capable of identifying and communicating the broad set of actions required for pa- tients to improve their health. This, in part, depends on applying data from patients’ comprehensive electronic health records (EHRs) to assess risks, design behavior change options, and optimize opportunities for better health. At Kaiser Permanente, for example, EHRs incorporate algorithms that analyze patients’ data to create individualized support tools for care. The tools are used by teams of caregivers across the health care setting as they actively work with and advise individual patients. Personalized in- formation is used in selecting treatments but also may be used in suggest- ing behavior changes, best weight and activity levels, and other health promotion opportunities. In its Colorado region, using intensified team care that is guided by patients’ own data, Kaiser has experienced a 72 percent reduction in deaths from heart disease. Halvorson noted that an ideal national health information system would: (1) be patient-centered and have continuity over time, staying with the patient, regardless of changes in provider, health plan, and geo- graphic locale; and (2) make the right thing easy to do, by including sys- tems that provide useful, timely reminders and instructions for patients and caregivers, so that together they can easily follow personalized health plans. The Doctor of the Future Victor S. Sierpina, University of Texas Medical Branch Dr. Victor Sierpina’s vision for integrative medicine includes the doctor of the future, who will be an integrative healer and whose practice differs in many ways from that of today’s physician (Table 2-1). The doctor of the future will provide care that is patient centered and comprehensive (mind, body, and spirit), care that is both high-tech (using genomic prediction tools and systems biology, for example) and high-touch, and care that focuses on preventing disease and injury. The practice would be team based, and might include complementary and

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43 THE VISION FOR INTEGRATIVE HEALTH AND MEDICINE TABLE 2-1 How the Doctor of the Future Will Function The Care Process Is….. The Doctor’s Role Will Be….. • A navigator • Patient centered • Part of a multidisciplinary team • Team based • Grounded in the community • High-touch, high-tech • Support social and environmental • Genomic and personalized policies promoting health • Preventive • Familiar with systems theory • Integrative And supports patients through…. And will follow…. • Complementary and alternative • Evidence-based, outcome-focused practices practices • Belief that the body helps heal • Principles for creation of healing itself environments • The lead of empowered patients alternative health practitioners, health coaches, and wellness mentors, as well as medical specialists. Putting the patient in the driver’s seat allows representatives from any number of disciplines to serve as the navigator, helping people sort through conflicting data as well as many difficult choices they must make during their lifetimes. Finally, tomorrow’s phy- sicians would consistently assess new evidence to ensure that their prac- tices meet the highest standards of quality and patient outcomes. Sierpina noted that there is a certain tension between the body’s ca- pacity to heal itself, and the mechanical model in which doctors act as fixers. One goal of future practitioners may be to guide and empower patients toward self-healing. Consonant with this approach could be use of the full range of natural treatments that include attention to the mind and body, use of the safest and least expensive interventions first, and mobilizing community supports. This vision of the future doctor does not reflect a purely in-the-clinic model. Future clinicians, if they are to be integrative healers, need to be out where people are and participate in social and environmental policy change. A focus on specific diseases and organ systems, rather than on over- all health, results in part from an imbalance in the U.S. physician work- force, which is dominated by medical specialists. Meanwhile, primary care doctors are in short supply. The ratio of specialists to primary care doctors in the United States is roughly two to one (GAO, 2008), while in countries with universal access that ratio is inverted, with three primary

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44 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC care physicians for every specialist. Overreliance on specialty care moves in the opposite direction from the healers of the future described above. It leads to poorer patient outcomes and sharply increased health care costs: “Instead of spending a dollar for preventing problems, we spend $2 or $3 fixing them,” Sierpina said. He suggested the following four ways to counter this trend: 1. Change reimbursement policies to ensure that it is not more prof- itable to treat disease than to prevent it. 2. Enable the patient encounter to be long enough for clinicians to obtain sufficient information and provide adequate behavior- change counseling. 3. Expand the pool of primary care providers to include nurses, physician assistants, and other professional groups. 4. Create incentives for students to enter primary care and for medical schools to teach them. Integrative Health and Cancer Ellen L. Stovall, National Coalition for Cancer Survivorship Patients with serious diseases and their families need easily accessi- ble, high-quality information about their disease, its symptoms, and treatment alternatives and their side effects, said Ellen Stovall. In fact, 70 percent of patients with cancer seek such information. Yet, some of the largest, most frequently used search engines and websites make it diffi- cult to find and access information on, for example, cancer and integra- tive medicine or cancer and complementary and alternative practices, even if the information is available on the site. To the National Coalition for Cancer Survivorship, use of evidence- based medicine and evidence-based practices are basic quality indicators in cancer care. However, this usage is difficult to monitor in the face of the typically uncoordinated and unsystematic approaches to cancer care chronicled by a succession of IOM reports, including From Cancer Patient to Cancer Survivor: Lost in Transition (2005) and Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs (2008). Some 95 percent of U.S. cancer patients are treated off protocol. “We have no idea what is happening to them, and that must change,” Stovall said, add- ing that patients are being treated outside any system that places high priority on patient-centeredness, quality assurance, and accountability for

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45 THE VISION FOR INTEGRATIVE HEALTH AND MEDICINE providers’ and health plans’ treatment decisions. Halvorson’s emphasis on treating each patient as a data point is therefore essential, she said. Prime characteristics of patient-centered care involve attentively elic- iting patient preferences and integrating mind, body, and spirit. However, cancer survivorship research reveals that when people are diagnosed with cancer, they temporarily lose the basic skills of everyday life. These in- clude skills in communication, information seeking, decision making, problem solving, negotiation, and speaking up for their rights. These are necessary tools that all patients facing a serious illness need in order to be self-advocates over the course of treatment. Lack of these skills can inhibit formation of a mutual, trusting partnership between patient and doctor. Diagnosis of a serious disease represents a crisis that challenges the integration of mind, body, and spirit at a time when people must draw strength from all domains and need extraordinary support from trusted individuals. Society embraces and emphasizes the race for the cure rather than the race for the care, said Stovall. The prevalent, laserlike focus on cure fails patients first and foremost—as well as everyone involved in their care—because cure may not be possible. Research involving three dec- ades of cancer survivors indicates that more than death, survivors fear pain and suffering for themselves and their families. They also fear being abandoned by their physicians, reiterating the importance of keeping pa- tients—not providers—at the center of the care process. In a truly pa- tient-centered system, patients would never be abandoned and, for those who cannot be cured, the emphasis would shift to what is possible— healing. Among the changes in the health system that would help patients with cancer and other serious conditions are greater acceptance and re- imbursement of integrative health practices; reimbursement for the time health professionals spend with patients to focus on healing; having cus- tomized treatment and survivorship plans that clearly describe the goals of care for the whole patient, not merely the services intended to combat the disease; and using the process of creating the plan to build strong re- lationships among clinicians, patients, and families.

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46 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC Communicating Health Mehmet Oz, New York-Presbyterian Hospital/Columbia University Medical Center If much of Americans’ health status depends on their personal be- havior—whether it be smoking, dietary choices, exercise, or engaging appropriately with the health system—health professionals will need to communicate with patients much more effectively, in ways that are clear, motivating, and accessible, said Dr. Mehmet Oz. Unfortunately, the current barrage of health-related communications that Americans receive often provides mixed messages, or incomplete, misleading, or out-of-context information. Even information derived from scientific studies can be confusing, such as conflicting information on the use of specific vitamins. In some cases, studies of issues the pub- lic cares about simply do not exist. As use of integrative practices advances, health professionals may gain a deeper understanding of why some of these approaches work. However, Oz said that it may be very challenging in some cases to find hard evidence to present to the public about many of these approaches, or to support their broader use. There is often little or no funding to support the necessary research for integrative approaches to health. For the time being, the best test of whether doctors should recommend particular practices to their patients may be whether they would recommend them to their own families, said Oz. The current medical system tends to focus on whether one interven- tion works better than another, while it almost never asks the question of whether a given intervention works better than doing nothing. Unfortu- nately, the latter is usually the question of concern to patients, said Oz. Patients want to know whether a recommended procedure is really nec- essary. Additionally, the current reimbursement structure encourages the use of expensive, sometimes invasive treatments over lifestyle changes, including nutrition and physical activity. The concept of integrative health has a global component—not just because it sometimes uses traditional therapies from around the world, but also because of the mindset, endemic in many cultures around the world, that puts health and illness in a broad context and looks at the whole patient. In other words, it is patient centered. This contrasts with the U.S. health care system, in which clinicians take a problem- based approach. The lack of patient-centeredness in the system degrades trust between clinicians and their patients. A loss of trust, Oz said, is the

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47 THE VISION FOR INTEGRATIVE HEALTH AND MEDICINE primary ailment plaguing the whole system. “Suffering is not just about pain. Suffering is realizing you don’t have control.” One way to increase patient control, Oz said, would be to create a “smart patient movement” that would empower patients to challenge cer- tain assumptions about the therapies they are receiving or, more broadly, to participate in attempts to improve the health system. Such a movement would underscore the public’s need to take more responsibility for per- sonal health as well as provide opportunities to do so. The smart patient and integrative health movements must therefore develop and promote user-friendly ways for people to obtain health information that are easy to use and include positive, motivating messages. Another way to increase patient control would be to encourage the use of health coaches and navigators. These important positions should be filled by knowledgeable people who can effectively guide and moti- vate patients to improve their health. Oz suggested that not all physicians have the time, the right expertise, or the interest in filling this role and that other professions should also be considered for it. People make their health-related decisions in a social, economic, family, and cultural environment. A number of features of those envi- ronments need to change, in order to improve health. For example, U.S. agricultural and food enterprises produce 3,500 calories of food per per- son per day. The need to sell these products puts into play powerful mar- keting efforts that make it difficult for many Americans to maintain a moderate, healthy diet. It becomes nearly impossible to follow writer Michael Pollan’s concise nutritional advice: “Eat food, not too much, mostly plants.” Another environmental factor affecting health is the lack of opportunity for physical activity, which could include simple solu- tions, such as neighborhood sidewalks that would allow children to walk to school. A quick poll of the audience demonstrated that, as children, most audience members walked to school, yet few audience members’ children do the same today. This demonstrated the fact that a few dec- ades ago, half of American children walked to school, Oz said, compared to less than 10 percent today. Finally, Oz suggested that a huge opportunity to improve the well- being of our nation would be to take advantage of the ServiceNation movement. Many service opportunities promote the health and well- being of citizens in need, the elderly, and children. High school gradu- ates, retirees, and many others could—and already do—participate in community service through government-sponsored programs or

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48 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC through organizations like HealthCorps, which teaches children about diet, nutrition, and exercise. Panel Discussion Following the panel presentations, questions from the audience were submitted for further panel discussion, which was moderated by Johns. Electronic Medical Records One participant noted that some people have difficulty obtaining in- surance coverage as a result of their medical history and the contents of their medical records, and queried whether such problems might be mag- nified if a national electronic health data system was created. Halvorson replied that universal insurance coverage will make it impossible to deny coverage for preexisting conditions. He noted that in Europe, where uni- versal coverage is the norm, there is no health screening for insurance. He said this is also true for 95 percent of Americans who currently have access to coverage. A corollary concern was raised regarding privacy protections for per- sonal data in electronic health records. While there can be no absolute guarantee that an individual’s medical record will be completely safe, Oz replied, in places such as British Columbia that have a national system for exchanging medical records, people find the advantages of the system outweigh their concerns about potential privacy breaches. Such a reac- tion might also occur among U.S. residents, except for those few with conditions that carry a real social stigma. Still, said Halvorson, “At the personal level we need to be absolutely bullet-proof on confidentiality issues,” and this requires high standards, tough rules, and strong en- forcement. Integrative Medicine and Social Determinants of Health Another participant asked how integrative medicine should address broad social factors such as social status, poverty, and education, which are important predictors of health status. Stovall responded by acknowl- edging the great disparities in the United States across many domains—

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49 THE VISION FOR INTEGRATIVE HEALTH AND MEDICINE income, education, and health. Despite these disparities, she said, when patients receive care that is culturally appropriate and respects the values and norms of their community, they are more likely to follow their care plan and have better outcomes. In the long run, one approach to leveling the playing field in health care, she said, would be through the universal health care coverage that Halvorson endorsed. Primary Care and Health Care Providers Other questions probed whether caregivers other than physicians could provide some of the needed primary care. Panelists discussed op- tions and noted that, while the health care workforce does need primary care physicians, it also needs geriatricians, nurse practitioners, physician assistants, and others who can provide primary care. Sierpina noted that health coaches and other intermediaries are also needed. Creating the right mix of professionals is one component of health reform, said Novelli. Panelists further indicated that increasing the sheer numbers of new professionals may be necessary, but will not be sufficient. Without changing the fundamentals of the system, new professionals would only be able to do more of what is not working now, said Sierpina. He noted that the contributions of nurses, physician assistants, and many comple- mentary professionals with long experience in prevention, primary care, and lifestyle issues could be increased. In addition, Halvorson said that tackling the problem of medical school debt might encourage more young physicians to enter the primary care field, even if it remains less remunerative than many specialties. PRIORITY ASSESSMENT GROUP REPORT 1 Integrative Medicine and Its Role in Shaping the National Health Reform Agenda Dr. Reed Tuckson delivered the priority assessment group report, which focused on the health care reform agenda. This summary includes 1 See Chapter 1 for a description of the priority assessment groups. Participants of this assessment group included Liza Goldblatt (moderator), Reed Tuckson (rapporteur) Susan Bauer-Wu, Jeffrey Bland, Sherman Cohn, Simon Fielding, Susan Folkman, Christy Mack, Diane Neimann, Margaret O’Kane, and Badri Rickhi.

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50 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC the priorities discussed and presented by the assessment group to the ple- nary session for its discussion and consideration; these priorities do not represent a consensus or recommendations from the summit. The group advanced the following three top priorities. The first priority identified by the group was the need to advance a new and shared vision for health—a national consensus that the health system should move away from the current predominant focus on the sickness model to a person-centered health, wellness, and prevention model that is holistic from birth to death, and involves individuals, fami- lies, and loved ones. It suggested that health care transformation should develop and build on a framework of individual responsibility for mak- ing responsible preventive and care choices that is supported by person- ally appropriate information and decision coaching. Promoting this vision for health requires consensus and a functional definition of inte- grative medicine that is easily understood and can be easily communi- cated. Additionally, the group also suggested a national campaign to inform important stakeholders about the shared vision for health and to more rapidly promote culture change. The second priority is to develop real evidence of the effectiveness of integrative health care. This requires demonstration projects that move beyond a vision to evidence for effective models. These demonstration projects require two key features. First, the projects need to implement reimbursement models for disease prevention and health promotion that align and offer incentives for change. These include incentives for physi- cians to provide more cognitive interventions; incentives for patients to act on their own behalf and to use tools to help them follow recom- mended guidance; and incentives for providers to form teams that can offer more patient-centered, coordinated, and holistic care. Second, the demonstration projects must be designed to evaluate whether the integra- tive medicine models are cost-effective for short- and long-term care. The third priority is to develop the definition and criteria for evi- dence in integrative medicine. To reflect integrative medicine’s whole- person aims, this requires an understanding of the research questions at- tendant to moving from single episodic interventions to systems biology approaches and clusters of interventions. It also may require new stan- dards of evidence for evaluation of quality and cost-effectiveness of out- comes. The group identified several key actors and stakeholders whose in- volvement is necessary to advance the above priorities. Key actors and stakeholders identified include:

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51 THE VISION FOR INTEGRATIVE HEALTH AND MEDICINE purchasers and insurance plans; physicians, medical educators, and “environmental” physicians; other health professionals including behavioralists and sociologists; hospitals; pharmaceutical and technology companies; researchers, including the CDC and NIH; political leaders; education community; food industry; and community organizations, such as churches. Finally, in response to the question of what goals are achievable in 3 years, the group concluded that significant progress will be marked by new initiatives, including demonstration projects that build on existing models of care and make good use of existing models, such as the Bravewell Collaborative clinical network sites, which provide a ready template for advancing innovations (These ini- tiatives should include a diverse set of health care practitioners.); articulating the definition and vision of integrative medicine, gaining support from key constituencies, and launching the na- tional campaign; active demonstration projects; progress in developing new evidence criteria; progress in reimbursement, especially because patient and physi- cian incentives are already progressing in the marketplace that can be built upon; and advances in the integrative medicine agenda, as patients are “ac- tivated” to take control of disease prevention and management.

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