Alternative Providers Turn to Rule-Making Process for Inclusion in CCOs

They want to see clear definitions of terms, and guidelines on reimbursement and provider capacity in these coordinated care organizations

March 15, 2012—Alternative health providers, including naturopathic doctors, chiropractors, massage therapists and acupuncturists, are turning to the Oregon Health Authority’s rule making process for coordinated care organizations (CCOs) to make certain their provider groups are on board.


The state agency’s rule making process for CCOs, which is expected to be completed within a month, spells out the rules and regulations that will govern CCOs in a way that reflects the legislative intent of House Bill 3650 and Senate Bill 1580, which set in motion the transformative healthcare system.


Coordinated care organizations will be comprised of patient teams that include doctors, nurses, behavioral health providers, community health workers, and other providers who will integrate physical, mental and dental healthcare to the 600,000 patients on the Oregon Health Plan. The hope is that by focusing on preventive care and reducing emergency room utilization, costs can be reduced. CCOs are expected to become operational in August.


Alternative provider groups scored a victory when language prohibiting discrimination against their provider groups was included in the legislation, as well as language allowing providers to appeal decisions made by a CCO to the Oregon Health Authority.


They were concerned that without such explicit language, they would have been excluded.


“Our experience as alternative providers has been that when anything is left vague…we are always eliminated or left out,” said Jan Ferrante, the executive director of the Oregon Chiropractors Association.


That discrimination, she and others say, comes from a deep-seated bias in the healthcare industry against alternative providers.


“[Managed care organizations]…almost categorically refuse to credential [naturopathic doctors], for reasons ranging from they’re governed by MDs and are unlikely to credential other providers, to their leadership is philosophically opposed to naturopathic medicine,” Laura Farr, president of the Oregon Association of Naturopathic Physicians, told legislators.


Although the non-discrimination language was an important battle to win, Farr believes more needs to be done to integrate alternative providers into the healthcare system.


And, she called the non-discrimination language passive, saying it “does little” to guarantee that patients will have the same access to naturopathic physicians and other alternative health providers. “The end result is very, in my opinion, generic language,” Farr said.


Farr and Laverne Saboe, the lobbyist for the Oregon Chiropractors Association, thinks there’s an opportunity during the rule-making process to create more explicit guidelines for alternative providers in CCOs.


Saboe said the rule-making process will determine what constitutes an adequate network of providers in a CCO, as well as provider types, qualifications and disciplines. Farr also said the process will include defining terms such as “provider” and “primary care provider,” and is hopeful that these definitions will explicitly mention naturopathic doctors and other alternative provider groups.


Another issue yet to be determined is how alternative providers will be reimbursed. The legislation gives CCOs the ability to reimburse providers at different levels based upon the quality of care they offer and their performance.


Saboe doesn’t believe alternative providers will be reimbursed at a lower rate than mainstream providers. “There are good evidence-based outcomes assessment tools…that’s not necessarily subjective,” Saboe said, including patient satisfaction.


Farr and others would like alternative providers to become integrated in CCOs throughout the state. “We’ll have better luck in some communities than we will in others,” she said.


At stake, she and others say, is whether Oregon Health Plan patients will be able to see providers that they believe can improve their health status. Laura Ocker, the president of the Oregon Association of Acupuncture and Oriental Medicine, points out that patients respond differently to medications and therapies, making flexibility essential.


“There have to be alternative therapies,” she said. “That gives the patient the full ability to look around and ask ‘what's effective for me?’”


“Consumers should have access to those providers…and there should not be such a restrictive network that it will be difficult for them to get an appointment,” Saboe said.

Image for this story appears courtesy of The Oregonian.

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As Governor John Kitzhaber, MD., has stated numerous times if we are going to substantively change health care here in the great state of Oregon, we must significantly change how we deliver health care not just how we pay for it. Part of changing must include at least some attempt at moving away from our growing over-reliance on all the synthetic pharmacological agents (drugs). We have become a nation of "pill poppers" approaching the four billion annual prescription purchases mark with direct costs of prescription drugs expected to reach $500 billion by the year 2015 when Oregon's new health system kicks in....and this figure doesn't include the indirect costs of treating consumers including many Oregonians who suffer the estimated 2.2 million adverse drug events/side effects resulting in some 700,000+ ER visits and 1 million+ hospitalizations. This year the CDC reported that 9 out of 10 poisonings are due to abuse of prescription meds with 40% being related to pain medications. 83% of Americans age 65 or older take at least one prescription drug daily, 75% take four and 11% take five or more. Some 1.6 million teenagers and children are prescribed at least two psychiatric drugs in combination with no clinical trials supporting this is even safe, 300,000 kids under the age of 10 are prescribed two psychiatric drugs in combination. Just this year it was reported that annual deaths due to all these prescription medications now out number traffic deaths. There are so many drugs that really don't work as the slick TV commercials would have us believe and so many natural evidence-based therapies that do....Yes, alternative health care providers agree with John Kitzhaber "We Can Do Better" but we have to be "in the game" Oregonians must have access to our services and the Governor's bill (SB-1580) is a start. Vern Saboe, DC

Our "Alternative Care" providers represent an extremely diverse but poorly regulated assortment somewhat unique to the States of Oregon, Washington, and California. Most States refuse to license naturopathic doctors, or eastern medical practitioners, and severly limit the scope of practice for accupuncturists and chiropracters - to protect their population from "unfounded practices", a pseudonom for quackery. In Oregon, our forefathers fashioned a "medical practice act" that preserves for the population the widest possible spectrum of choices in healthcare resources - a very different emphasis. We thus became home to the national colleges of naturopathic medicine, eastern medicine, and numerous chiropractic colleges, whose graduates have a severely limited spectrum of choices upon graduation - producing an increasing concentration of alternative practitioners in Oregon. I don't disagree with the original commenters statement on our societys over reliance on medications, but the implication that the inclusion of chiropractors and accupuncturists in our CCOs would remedy that problem is ludicrous. The decision the Health Authority must make is which providers to include in a basic healthcare plan that the taxpayers will fund. Not including alternative providers does not limit access for those who choose to use their services. Although some chiropractors voluntarily limit their services to patients with chronic back and neck pain, others claim that they can treat EVERY medical problem, including psychiatric and developmental problems with spinal adjustments. As a taxpayer, I do not want to pay for the weekly spinal adjustments recommended for a teen with behavior problems by his chiropractor when there is no peer reviewed support for its effacacy beyond the opinion of fellow chiropractors. Let's root out bad practice wherever it exists - not encourage it's expansion. Don LaGrone, M.D.

"Conventional medicine" irritates even some of its own when it lobbies to maintain monopoly privilege. "Conventional" practitioners who insist on putting down the judgment of medical customers (formerly known as patients) will suffer a loss of business, even if their privileges are largely maintained in current legislation. So many western-states individuals want agency and want practitioners who can play well together. The latest Grand Round lecture at OHSU that I listed to, on-line, speaks of integrative information and how it must be considered. A recent TED talk features an M.D. who had to go to on-line sources to get out of a reclined wheelchair, where conventional medicine had left her. My grandfather was an old-style M.D. That model does not work for me. I want to know what personalized-medicine (known as N=1 at MIT) says, and what the outcomes are for particular treatment choices. I am many years beyond the average expected life expectancy of a person with the kind of cancer I was diagnosed with. I attribute that to integrative medicine, not to conventional medicine alone. I maintain that opposing client choice is not even good for the kind of medicine that might be able to enforce that for a few more years.

There is only medicine;there is no "alternative medicine". All medicine must follow the scientific method. When the so called "alternative" medicine providers can submit scientific method studies,let alone agree to do them,then and only then (and based on evidenced based improved and/or equal outcomes),should we the tax payers pay for such. Michael Kaplan

I think there are some widespread misunderstandings about terms like " scientific evidence" when applied to current healthcare practices in our country. Contrary to popular thinking, most medical doctors (MDs) have limited academic training in the scientific method and in the statistical analysis of data, including the analysis of multivariate data. And this deficiency leads to widespread prejudice and bigotry. For example, is the use of acupuncture, which continues to be used in modern Chinese hospitals, along with western medicine, "evidence" of its value in pain management? Is the use of acupuncture by veterinarians "evidence" of its efficacy, and beyond concerns by the less educated that it is "all in the mind" of the patient/animal? What about the MDs (Medical Acupuncturists) and other western trained healthcare professionals who want to adopt acupuncture into their practices under the term "dry needling" with limited training? Are these professionals motivated by the belief that the practice of acupuncture actually works? Another example: Is the use of pharmaceuticals for off-label uses justified- i.e., those applications of medications for which no rigorous scientific studies, such as Randomized Controlled Trials (RCTs), have been perfomed ? There are increasing concerns that many of these uses are harmful to patient health and that they have circumvented the pharmaceutical industry's own "standard' for scientific credibility. We could go on to ask if a Phase III RCT, with about 1000 patients, really covers the full genetic variation in the population to which the drug will be administered. If the sampling is limited, how do we address (i.e., quantify) the magnitude of the risks imposed on the population by these sampling errors and the widespread prescribing and use of pharmaceuticals for which we have limited safety information. Examples, such as the ones listed above, are numerous and show us the deficiencies in our current healthcare system brought about by the persistence of ignorance in "conventional" medicine. Should pharmaceuticals and surgery be the only options in our healthcare system to manage illness and to promote health? Should MDs be the only healthcare providers to assess the scientific basis for "evidence"? The current thinking is that only MDs have the know-how to make judgements on all issues involving healthcare. To me, this is a biased position and, based on the evidence, has not served our country or our people well. As a scientist with three decades of professional experience in the sciences, I believe that some changes are definitely needed to the way "conventional" medicine is being practiced in our country. In my opinion, "evidence" should be linked to outcomes. And statistical measures will help us understand these issues better. Our "conventional" system of medicine, with its high expenses and relatively poor outcomes (i.e.,ranked 38th in the world), is currently lacking the diversity in thinking needed to become more effective and more economical. To be more sustainable and resilient. Let us hope for a few years of inclusive thinking to fully assess what works in healthcare and what doesn't, with practitioners from other systems of medicine (i.e. ,Asian/Chinese medicine, Chiropractic, Naturopathy) offering their own input on how we can control costs better and how we can improve health outcomes in this country. PK Melethil, L. Ac.