The daunting challenge - Complementary and Alternative Medicine

Physician Executive, Nov-Dec, 1998 by Elizabeth Brown

There is no question that the past few years have seen a tremendous surge in interest in what has come to be known as complementary and alternative medicine (CAM). Health plans contemplating adding CAM benefits face a daunting challenge. How should a plan define CAM benefits? How should a plan define appropriate CAM providers? How can these benefits be managed? Will the addition of CAM benefits undermine coverage policies for conventional biomedicine? The answer to these questions lies largely in uncharted waters, as even CAM advocates will agree that many alternative therapies (even those like Oriental medicine which has been in practice for some 5,000 years) have not yet undergone the type of rigorous, evidence-based analysis that is required to validate conventional biomedicine. This article explores options for CAM benefit design by considering two basic approaches-creating an uninsured benefit or insured benefit.

Key Concepts: Complementary and Alternative Medicine (CAM)/CAM Benefit Design/Insured Benefits/Uninsured Benefits

THERE IS NO QUESTION THAT THE PAST FEW YEARS have seen a tremendous surge in interest in what has come to be known as complementary and alternative medicine, or CAM. This growing interest may be related to dissatisfaction with conventional western medicine (also known as biomedicine) which is perceived as high-cost technology driven, associated with significant morbidity, and focused on the disease rather than the whole patient. In contrast, CAM is perceived as low cost, encompassing a more holistic approach to both health and disease, and significantly safer than biomedicine. Clearly, CAM enjoys an under-appreciated popularity In this country.

Two events in focused the attention of the biomedical community on CAM. The National Institutes of Health established the Office of Alternative Medicine (OAM) in 1992 to identify and evaluate CAM therapies. In addition, the OAM supports and conducts research and research training on CAM practices and disseminates information. In 1993, David Eisenberg and his colleagues published an article in the New England Jo urnal of Medicine which estimated that Americans made 425 million annual visits to CAM providers, the majority paid for out of pocket.' Eisenberg reported that annual CAM visits exceeded those made to primary care physicians. These seminal events served to raise awareness of alternative medicine approaches by bringing CAM to the forefront of the medical community and providing formal recognition of Its potential health benefits.

Attention was further focused on CAM providers with the 1995 passage of a Washington state law requiring health insurance plans to provide access to alternative health care providers (chiropractors, acupuncturists, and naturopaths) to treat conditions that would be otherwise covered under their health plan. Finally, some health plans began introducing limited CAM benefits in some of their products. The combination of all these events has created competitive market pressure and raised member and policyholder expectations that CAM benefits should be included as part of a health plan. In addition to market pressures, the cost-saving potential of CAM therapies has sparked additional interest among health plans.

Health plans contemplating adding CAM benefits face a daunting challenge. How should a plan define CAM benefits? How should a plan define appropriate CAM providers? How can these benefits be managed? Will the addition of CAM benefits undermine coverage policies for conventional biomedicine? The answer to these questions lies largely in uncharted waters, as even CAM advocates will agree that many alternative therapies (even those like Oriental medicine which has been in practice for some 5,000 years) have not yet undergone the type of rigorous, evidence-based analysis that is required to validate conventional biomedicine.

Definition of CAM

The definition of CAM itself is an interesting discussion. The OAM offers the following:

"CAM is a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well-being. Boundaries with CAM and between the CAM domain are not always sharp or fixed. " (2)

This relational definition suggests that one culture's CAM could be another's "politically dominant health care system." Therefore, using this definition requires also defining our politically dominant health care system; by exclusion CAM represents everything else. The NIH panel on Definition and Description of CAM suggests that "politically dominant" reflects broad acceptance as evidenced by "...medical practice laws, legally recognized accreditation and rights of self regulation, third-party payment, privileged access to public research moneys and to prestigious publication venues, high status, and so forth." (3)