Like every state, Oregon is struggling with the unsustainable costs of taxpayer-funded health care programs. In an attempt to tame this beast, Oregon recently established a system of coordinated care organizations, or CCOs, to (as the name suggests) coordinate medical, mental health, and dental care for residents enrolled in Oregon Health Plan, the state’s Medicaid program. The new system requires supervision of this coordinated effort by the participant’s primary care physician (PCP). Not one of the 15 newly-minted CCOs has credentialed a naturopath as a PCP even though naturopaths are licensed as such by the state. Needless to say, the naturopaths are not pleased by this development.
The big stumbling block appears to be the state’s requirement that CCOs practice evidence-based medicine as a cost control measure. Unfortunately for naturopaths, evidence-based medicine is not their strong suit. Apparently scientific plausibility is not much of a concern either.
As one chief medical officer of a CCO explained in a news report,
We have an obligation to the state and to the community that the providers on our panel will deliver the evidence-based care required by the Oregon Health Plan. . . . We need to make sure that all of the providers who are empanelled meet those basic standards of care.
He has good reason for concern. Here’s David Gorski’s apt summary of naturopathic practice:
a hodge-podge of mostly unscientific treatment modalities based on vitalism and other prescientific notions of disease. As a result, typical naturopaths are more than happy in essence to ‘pick one from column A and one from column B’ when it comes to pseudoscience, mixing and matching treatments including traditional Chinese medicine, homeopathy, herbalism, Ayurvedic medicine, applied kinesiology, anthroposophical medicine, reflexology, craniosacral therapy, Bowen Technique, and pretty much any other form of unscientific or prescientific medicine that you can imagine.
(This post collects references to several other SBM posts on naturopathy, including Kimball Atwood’s excellent four-part series, and here’s another one too.)
The executive director of the Oregon Association of Naturopathic Physicians (OANP) dismissed evidence-based medicine as a “red herring” although she didn’t say what she thought the real reason was or what motive the CCOs might have to obfuscate things. After all, if naturopaths could actually deliver good primary care at a cost equal to or less than M.D. or D.O. PCPs, you’d think the CCOs would jump at the chance to include them.
Fighting the “red herring”
Undeterred by this “red herring,” naturopaths have engaged in a media campaign to fight their exclusion. Unfortunately for them, the resulting media coverage simply serves to shore up the CCOs’ case against them. (You can access news reports here: Bloomberg BNA, The Lund Report Sept. 19 & Oct. 30, Portland Business Journal, The Oregonian.)
Of course, there is nothing like the touching anecdote to demonstrate how the heartless state of Oregon is going to wrest Medicaid patients from the loving arms of their naturopaths and onto the cold examining tables of M.D.s and D.O.s. But you have to question whether these examples really did the naturopaths any good. Consider these media accounts of naturopathic patients who want to keep their naturopath as their PCP:
- Naturopath gives disabled boy a single homeopathic dose of arsenic for constipation and mom says “he pooped every single day for a year after that.”
- Infant diagnosed with posterior urethral valve; doctors tell mom that he will most likely need kidney transplant before age 18. Naturopath tracked progress and, according to mom, they could see “it head bit by bit to more normal.” Naturopath used “various non-toxic boosters of kidney function, including homeopathic and herbal medicines.” Now almost two years old, boy is described by mom as healthy.
- Naturopath specializing in pain management says he can “promote healing” of Crohn’s and colitis and is “able to get people’s pain managed so that they can start de-toxing.”
- Patient who suffered stroke 10 years ago says her “nerves seem to be regenerating and she’s walking better.” Attributes this to acupuncture treatments provided by her naturopath.
In fact, in all the media reports there was only one reference to any evidence at all: “13 studies in a ‘Systematic Review of Outcome Studies of Whole Practice Naturopathic Medicine, presented at the International Research Congress on Integrated Medicine and Health.” This turns out to be a poster presentation from the conference whose purpose was stated thusly:
Individualized combinations of therapeutic modalities and remedies are generally the rule in naturopathic practice with selection determined by the system’s principles and guidelines. With the wide variation in real-world use, evaluating the whole practice best assesses the overall benefits and risks.
Note how this description fits perfectly with Dr. Gorski’s take on naturopathic practice. The authors continued:
We have so far identified 12 [not 13] studies fitting inclusion criteria with a variety of designs in anxiety, tendinitis, temporomandibular joint disorder, low back pain, general pain, hypertension, multiple sclerosis, menopausal symptoms, cardiovascular risk and type 2 diabetes. Six were randomized trials including 2 with cost components, one a comparative prospective observational study, one a prospective single group observation, and four were retrospective. All showed some evidence of effectiveness though most had methodological weaknesses. No studies in acute disease meeting criteria were found.
And they concluded:
The review provides evidence of effectiveness and cost savings that merit further investigation of naturopathic care for chronic disease.
Thus, the most favorable evidence mustered is weak on 10 chronic conditions and non-existent on acute diseases. It doesn’t appear that a concern for evidence-based medicine is a “red herring” after all.
(A digression: The International Research Congress on Integrative Medicine and Health was held in Portland, OR, this year, and sponsored by, among others, the Consortium for Academic Health Centers for Integrative Medicine and your tax dollars, in the form of the National Center for Complementary and Alternative Medicine. A brief perusal of the oral and poster presentations, conveniently available on-line from Bio-Med Central, is enlightening regarding the exciting research taking place in the world of integrative medicine. In addition to the poster presentation on naturopathy mentioned, a brief sampling includes: “Development of the phlegm syndrome questionnaire: a new instruction to assess traditional Chinese medicine syndrome for angina,” “Current practice among acupuncturists treating threatened miscarriage in Australia and New Zealand,” and “Does practicing Reiki alter the electromagnetic field of heart and hands of practitioners?” There is much, much more on-line and those of you with a few minutes to spare won’t be disappointed if you take a look.)
Argument and rebuttal
So if evidence-based practice, and even scientific plausibility, is out the window, why should the CCOs allow naturopaths to participate as PCPs? Here’s what they argue, taken from both media accounts and a white paper prepared by the OANP, along with my comments in italics:
There is a shortage of PCPs.
Substandard care is not the solution to the PCP shortage.
Patients have a right to choose among health care providers.
The state has an obligation to get the best care for the lowest cost when the taxpayers pick up the tab. There is no “right” to choose health care that does not fit within those parameters.
Naturopaths are licensed by the state as PCPs.
Again, the state has an obligation to taxpayers to get the most bang for the buck with public funds. Who the state legislature decides to license is of no relevance to this issue. The law does not require CCOs to accept “any willing provider.”
Oregon law says the CCOs can’t discriminate against any licensed health care provider.
A decision that exclusion equals discrimination would be in direct conflict with the law’s requirement that CCOs practice evidence-based medicine. Failure to follow evidence-based guidelines and use of modalities, such as homeopathy, which don’t even have a plausible basis in science and certainly no evidence of effectiveness, is a rational basis for the decision to exclude naturopaths. As is their inferior education and training when compared to M.D. and D.O. PCPs.
A special naturopathic vaccination plan
The OANP’s white paper deserves special comment. Noting that the naturopathic position on immunization is apparently a concern, it offers this less than reassuring statement:
[B]ecause naturopathic care is by definition patient-centered, many NDs will customize the vaccination schedule to address the patient’s risk factors, environment, and personal beliefs.
I guess being “patient-centered” includes skipping the U.S. Centers for Disease Control’s recommended vaccination schedule. They even claim this approach can actually increase vaccination rates in patients who would otherwise refuse vaccinations. Either this is a new, untried strategy or it’s not working, as these studies would indicate:
Pediatrics (2006): Found negative influence of naturopaths on mothers’ decision to vaccinate children.
Canadian Journal of Public Health (2010): Consultation with a naturopath significantly decreased the likelihood of receiving a flu shot among women in contact with young children.
Maternal and Child Health Journal (2010): Children in Washington State were significantly less likely to receive each of the four recommended vaccinations if they saw a naturopathic physician. Children aged 1–17 years were significantly more likely to be diagnosed with a vaccine-preventable disease if they received naturopathic care. Pediatric use of complementary/alternative medicine in Washington State was significantly associated with reduced adherence to recommended pediatric vaccination schedules and with acquisition of vaccine-preventable disease. (Similar results for chiropractors.)
I’ll just add that famous CAM line, “further studies are needed,” and suggest that until the evidence demonstrates otherwise, naturopaths should be viewed with a healthy suspicion when it comes to advising patients about vaccinations.
The government caves, once again
Of course, when all else fails, it’s time to turn to friends in state government for special treatment. After all, having gotten licensed in the first place via the magic of legislative alchemy, CAM providers are not shy about returning to the well for more goodies. Although the state mandated that CCOs base medical treatment on evidence, Oregon has now turned around and decided to give naturopaths a 90-day reprieve by requiring that CCOs pay for naturopathic treatment during this time period. If the CCOs exclude naturopaths after 90 days, apparently Oregon Health Plan participants will be able to see a naturopath anyway, outside of the managed care system. Paid for by the taxpayers, of course.
This is but another deplorable attempt by CAM providers to circumvent health care reform. The venue may be smaller but the tactics are the same. Under the mantle of state licensing legislation, which allows a scope of practice at odds with their actual education and training (not to mention basic science), CAM providers argue that they actually have the skills the state legislature has gifted to them. With the help of “anti-discrimination” provisions inserted into health care reform legislation by sympathizers, they then hold the threat of litigation over the heads of health care organizations trying to toe the line on costs. These tactics are simply a variation on a familiar theme, that of forcing health insurers to cover their services via another legislative favor, health insurance mandates and “any willing provider” laws. Until the state legislatures and federal government are willing to stop this nonsense, the public’s health will remain at the mercy of the fanciful remedies concocted by CAM providers and funded by us all.