A Win-Win for Oregon: Naturopathic Doctors as Primary Care Providers
OPINION -- As a teen and young adult, I was fascinated by paleontology, enthralled by evolutionary biology and captivated by biophysics. There were big questions to answer: Where did we come from, how did we get here, where are we going? I knew I’d find answers in med school.
I became a research assistant at a prominent hospital. I learned that conventional biomedicine was not for me. Like so many of my fellow NDs, I found naturopathic medicine care quite by accident. Because of an acute health condition that wasn’t resolving with conventional medical care, I saw an ND who treated me with all the natural means in her toolkit. Shortly afterward, my medical specialist was puzzled by my recovery and curious about the cure. I knew that naturopathic medicine was something to pursue professionally.
By 1996 I graduated from NCNM, followed by residency and full practice. Much has changed in naturopathic medical education and clinical practice since then. One constant is that naturopathic medicine is founded in science—NDs are required to study the basic, biomedical and clinical sciences for two years. As persistent myths are clarified about our practice, licensed states have doubled, active NDs in the field have tripled, and NDs in Oregon are licensed primary care physicians.
The Changing Field of Naturopathic Medicine
Our foundation is anchored in natural healing, including botanical science, nutrition, hydrotherapy, physical medicine among others. In the past 20 years there has been an increasing focus on other therapies our patients require—pharmaceuticals, for example, broad lab testing, and a proliferation of natural research. NDs know from clinical experience and years of education the interactions that can arise between a prescribed herb and, say, a diabetic medication. They have developed the necessary medical skills and scope of practice to know when and what size of a dose of herbal or pharmacological medications to prescribe for their patients.
NDs, unlike their medical counterparts, practice whole-systems medicine. Our intake examinations can take two hours as we examine not only the presenting condition, but also what nutritional guidelines, if any, our patients use; how is their sleep; do they exercise; are there issues affecting them emotionally? This range of questions helps us to zero in on root causes and present behaviors affecting their presenting condition. We listen to our patients—and engage them in their treatment protocols.
Thomas Bodenheimer, MD, MPH, at the University of California, San Francisco Center for Medical Excellence in Primary Care (key author of the clinical curriculum used at NCNM), said, “Ten percent of a person’s health is determined by healthcare, and 60 percent is determined by self-management issues, community issues, education, class, race; anything but healthcare.” Bodenheimer maintains—as NDs have for decades—that health education and behavior change are key to helping patients develop skills associated with managing their health improvements. Bodenheimer notes that this “patient action plan” is incremental, or as he says, “Baby step by baby step.” Patient self-management may be a relatively innovative concept for Western medicine, but making patients partners in their healthcare has long been standard practice for NDs.
Preventive medical care is not only about more tests; it is about rethinking personal and professional responsibility for health maintenance for the individual. It is about coordinating care. It is about the individual. It is proactive, inclusive and always patient-centered. Public acceptance and recognition for what we do as medical professionals has been increasing in Oregon and throughout the United States. Just this summer, the Oregon Health Authority certified NCNM Clinic as a top-tier patient-centered primary care home in recognition of our high-quality patient-focused care, coordination of care by our medical teams and our emphasis on preventive care and management of chronic conditions.
The Argument for Natural Medicine
There is little doubt that the court of public opinion is changing in favor of naturopathic medicine. What has changed in recent years to shift the perception of naturopathic medical care from “alternative” to “primary” care? The answer is that patients decide how their healthcare is managed. They know that the U.S. health system is unwell, that it is not working as a system and it is not working for them as individuals. What was once marginalized as “alternative” is becoming a reliable route to healthcare, partly because there are alternatives to pharmaceuticals and invasive procedures, and definitely because these so-called “alternatives” work very well. Even so, the study and practice of pharmaceutical medicine by NDs is only part of the story.
Insurance coverage is another. NDs are covered by Medicaid through the Oregon Health Plan and CareOregon. With the exception of Oregon Health COOP and LifeWise, insurance carriers still balk at covering natural medicine. Aetna, for example, recently served notice to NCNM that it did not recognize our status as primary care providers in Oregon. That company’s logic, despite federal and state legislation to the contrary, stems from recognizing NDs only as “alternative care” practitioners, not as PCPs. For companies like Aetna, this categorization guarantees that naturopathic doctors will continue to be reimbursed significantly less for performing the same services as medical doctors. Meanwhile, the shortage of primary care physicians grows ever larger—to the detriment of our patients who are their bread and butter customers.
NDs diagnose and treat the entire gamut of conditions, from minor ailments to acute disease. We order labs, share chart notes with a medical team, order medical devices, work with hospitals and refer to specialists—including MDs—as the case requires. We can ameliorate the critical shortage of PCPs. The state of Oregon recognizes us. The Affordable Care Act recognizes us. Yet intransigent barriers for NDs under insurance plans continue to persist. This largely unsustainable behavior is increasingly at odds with newly insured patients who, more than ever, are seeking NDs as PCPs.
NDs know that the demographic of the American patient population is changing—and what we see is not encouraging. We face much higher levels of acuity and co-morbidity in our patients than ever (doctor-speak for much sicker patients presenting with two or more chronic conditions—for example, patients with a combination of diabetes, high blood pressure and heart problems). In one six-month period, we saw a jump of 85% in the number of our Medicare patients. These are patients who have been sick for some time. Many report they were unable to seek medical care earlier, often due to a lack of financial resources.
Despite the gains of the ACA, there is a tidal wave of seniors and uninsured patients who wait months for access to a small pool of PCPs. At the same time, NDs who absolutely meet the standards of care as required by the state, are an underutilized resource. We believe that the rising chronicity rates in America, coupled with an acute shortage of PCPs, is a strong argument that it’s time to remove all the remaining barriers to quality standards of care from all licensed, qualified providers. The team of practitioners at NCNM is ready and able to take action in support of every patient’s health.
Regina Dehen, ND, LAc, is dean of clinics at the National College of Natural Medicine.