In recent weeks, two influential integrative health organizations each chose to feature presentations on the expansive, multidisciplinary, and remarkably patient-choice integrative pain pilot associated with the University of Vermont Medical Center (UVMC). The presentations for the Academic Consortium for Integrative Medicine and Health and the Alliance to Advance Comprehensive Integrative Pain Management (AACIPM) featured the project’s remarkable, multi-stakeholder partners: the state’s dominant payer, Blue Cross Blue Shield, the Vermont Department of Health, and the academic medical center. Included in the latter was the project’s research leader, longtime integrative health policy activist and prior NIH National Center for Complementary and Integrative Health adviser Janet Kahn, PhD, LMT. The parties shared early outcomes from the unique bundled payment model. Many consider the strategy a potential pilot for the nation. What is being discovered? Can it be implemented elsewhere?
This pilot is the second major pilot from Vermont relative to integrative strategies in the past half decade. The first was an acupuncture coverage pilot in a Medicaid population funded through the state’s legislature and led by then Society for Acupuncture Research co-president Robert Davis, MS, LAc. Davis, who is privileged at the UVMC, is the lead acupuncture clinician in the current pilot. He was part of a team that published those findings in Global Advances in Health and Medicine on the prior Medicaid pilot. The patient reported outcomes highlighted the effectiveness of the covered services of licensed acupuncturists:
Ninety-six percent of patients said that they would recommend acupuncture to others with chronic pain, and 91% reported qualitative improvements, including physical (31%), functional/behavioral (29%), and psycho-emotional (24%) improvements.
What the team did not report in GAHM was an outcome that was perhaps more important to policy makers. The pilot was begun as a response to the opioid crisis. In that arena, indicators were that for the 30% of patients in the trial using opiates when acupuncture services started, just over a third (38%) reported reducing their use. The chief medical officer for the Department of Vermont Health Access acknowledged the positive patient experience but added: ‘‘I don’t think it was a compelling case that acupuncture led to a decrease in opiate use.’’ The legislature did not move to expand coverage.
Spoiler alert. The outcomes of the bundled pain pilot showed a similar pattern. The patient reported outcomes are compelling. Yet in the integrative pain pilot, the perhaps most decisive issue, relative to costs rather than opiate use, appears more problematic for widespread adoption.
The extraordinary pilot
The ;program manager for UVM Integrative Health is Cara Feldman-Hunt, MA, NBC-HWC. There is no question that the program developed through that initiative and led by UVMC’s director if its Comprehensive Pain Center, Jon Porter, MD, is an extraordinary embodiment of integrative philosophy.
- An “acceptance and commitment therapy” group process helps set the context and re-frame the care experience.
- The choice of integrative services is a veritable candy shop for anyone interested in exploring: conventional medicine, acupuncture, massage, Reiki, medical nutrition, yoga, physical therapy, occupational therapy, and cranialsacral therapy.
- A significant portion of the work was in groups.
- The collaborative process among practitioners is built in. Between 15-20 people involved with the program met weekly.
- The participating human being, while guided, remains in charge of which of the integrative services he or she chooses.
- The bundled payment model allows individual choice and pay based not bon individual fees for multiple services but on the whole of the experience.
- And all of this was engaged through a remarkably integrative investment of Vermont’s top governmental, payment, medical and integrative health stakeholders.
The AACIPM Presenters on the Vermont Pilot
The 51 participants in the first 6 cohorts were a mix of integrative naive and integrative experienced individuals. They were invited by BCBS based on previously high service usage. In the program, the participants averaged 30 sessions during the 8 weeks of its duration. These consisted on average of 13 support group sessions and 17 other therapeutic session of their choice. Patients liked it and reported the program as effective. On each of 12 indices from three instruments – PROMIS-29, Self-Compassion Scale, and Brief Resilience Scale – patients showed improvement. Kahn, the researcher, presented the findings with appropriate caveats:
That all 12 have moved in a positive direction allows me to feel hopeful that despite the small sample size, this is not just chance noise in the system, it is an indication that something good appears to be happening and should continue to be investigated.
Where the rubber (also) meets the road: cost
The concept of “patient-centered” in US health care has an asterisk that is applied when strategies from outside the dominant practice are under consideration: cost. The bottom line was reported out by Josh Plavin, MD, MPH, MBA, the chief medical officer for Blue Cross Blue Shield. (In Vermont, BCBS has a virtual monopoly among private insurers.) In the bundled payment environment, the dollars are based on per member per month (PMPM) payment to UVMMC. Most providers are employees of UVMC and these payments cover their salaries. In the present UVMC model, the acupuncturist (Davis) and the massage/craniosacral therapist (Kahn) are independent contractorss who receive from UVMMC a PMPM payment. (As such they may be the first such providers to have been pain in this manner.)
For the first 32 patients, the cost of the expansive program was up 18% to $1415 per participant during the program from an average PMPM cost prior of $1,197. Kahn was direct in her assessment:
Of course we would have like to have seen the costs go down. We don’t really know what the time frame will be for best assessing the impact on cost of the program. I certainly hope that people – the insurers, government agencies and the medical center – will be happy with the extent that all of the pain, anxiety and other issues that accompany chronic pain went down, and things like resilience and self compassion went up.
While the patient-reported outcomes build an affirmative case, the present cost data will not be helpful in successfully selling this model into other systems. The Vermont pilot also has two other characteristics that generally support a successful environment but that are not easily transferable. Both Kahn and the acupuncturist Davis are not only seasoned clinicians but also nationally experienced policy leaders. These are rare combinations. In addition, Feldman, an energetic and integrative-committed organizer with skills enhanced by completion of the Duke Leadership in Integrative Medicine program, is also a rare force whose uniqueness can easily be discounted.
Layered on this integrative core is a collaborative culture, based on relationships, that Kahn called “Vermonty” that supports such innovation. Politically, Vermont’s interest in the health of all that has driven the state toward a single payer model. The monopoly-like position of Blue Cross Blue Shield makes it relatively efficient to bring private insurance to the table. Vermont is a small state in which everyone in healthcare seems to know each other.
Kahn believes that while “some things about the origins are Vermonty, the program itself could be scaled.” She acknowledges that “a Cedars [Los Angeles] or Columbia-Presbyterian [New York] or a Boston teaching hospital might require 5 or more locations to reach their populations” and this would require a good deal of education and preparation of staff. Yet Kahn also sees that in their pilot they could have done better in multiple ways where another program might be more successful. She singles out the potential to develop stronger relationships with primary care doctors from the outset.
Kahn also shares that the clinician team is urging BCBS and UVMMC to lengthen the program to 12 weeks of services. From the beginning of the pilor’sa conception, Kahn adds, those on the clinical side have made the case that they wanted the collaboration to be able to explore and shift the exact dimensions of the model. She notes a relevant observation:
We noticed that at week 5 participants started getting anxious about it ending. We’d like to expand it out to get at least 8 good weeks of therapy, and we think we need a 12 week program for that.
BCBS and UCMMC are considering the request for an extended program. That wouldn’t be the only change. Like everything else in health care and life the past few months, the program has been disrupted by the COVID-19.
Yet Kahn shares that the program is moving forward with a new cohort of 6 as part of a new normal in which much of the program will be virtual. Kahn worries at the losses from the participants not having a chance to form relationships via the face-to-face group meetings, and even the waiting room time ahead of sessions.
It’s a significant concern. Many years ago when Dean Ornish, MD was asked which of the components of his pioneering multi-modal lifestyle intervention – diet, mindfulness, exercise delivered in a group context – was most responsible for the success in reversing the atherosclerosis that shocked the cardiology world. He replied that it was the group. The UCMC team will be served to creatively explore how virtual gatherings can be best utilized to enable such relationship building and empowerment.
Meantime, the anticipation of this set of stakeholders teaching multi-stakeholder collaborations nationwide feels a bit like the patient at 5 weeks, worried that the program might come to an end, like the earlier acupuncture Medicaid pilot, before the optimal model is innovated, and is producing its optimal outcomes.