Requiem for an Integrative Dream

The idea of ‘integrative health care’ has captivated people for several decades, and many examples have come and gone. Some medical delivery systems have incorporated some providers into care delivery; most have not. Some business models have survived; many have not. One of the more important local (Minnesota) sets of accomplishments in integrative health care occurred from 1998-2000, when some novel clinic models were established. As a product of the leadership of Dr. John Allenburg, president of NWCC and its successor host institution Northwestern Health Sciences University, there were five notable experiments, all distinctive and unique–especially for the time.

Dr. Allenburg had held that there were three types of models that reflected real-world needs and thus should inform the school’s efforts. One was a multidisciplinary provider team, housed in a single clinic; another was a virtual team, housed at different locations but functioning together with electronic facilitation; and another was that of an independent solo practitioner, able to craft interdisciplinary referral relationships as their circumstances, values and patient needs dictated. Based on this strategic vision, NW created five experimental clinics. With the news that NWHSU sold the Natural Care Center at Woodwinds in Woodbury MN on 6/29/15, the last chapter in this effort is over. Whatever integrative efforts occur will come from on-campus or other new opportunities. Is this a net gain, neutral, or a net loss? As Dr. John has said many times, “Where you stand depends on where you sit.”The first integrative clinic model came out of a relationship with the advanced practice nursing program at Metropolitan State University in St. Paul. Their visionary dean, Marilyn Molen, had faculty who saw the opportunity for NPs to provide greater clinical leadership with an explicit re-commitment to the relationship basis in nursing. We set up a clinic with a NP as clinic director and a DC providing chiropractic services. It was an innovative model, and though the NP worked with a MD for any prescription needs, the physician was never on site. The clinic operated for a couple of years until other faculty fractured the effort over the concept of NPs acting with such independence; start-up grant money was returned, the dean resigned and the clinic closed. Exploring the opportunity in relationship-building between DCs and NPs was rewarding and insightful, and the patients loved it.

Another integrative model was set up at a facility for homeless women and children in Burnsville, called Mary’s Shelter at the time. A doctor of chiropractic worked part-time on site, providing health education, counseling, comfort and adjustments to the population there, coordinating care when needed with the medical staff that came through the facility on a regular basis; they shared clinic space. The relational attributes of a female DC were rarely more important than in the care of this traumatized population.

Another was set up at La Clinica, a physician-led low-income clinic in St. Paul serving (at the time) a mostly Hispanic community. Chiropractic and acupuncture were popular clinical options there, and many patients were served during the several years of Northwestern’s participation viagra precio farmacia.

Yet another was set up on Payne Avenue in St. Paul, in a remodeled building that became a clinic staffed by a DC, an acupuncturist and a massage therapist. The DC was Hmong, and a fascinating set of relationships was established with many in the population of immigrants who favored natural approaches to healing and were deeply suspicious of Western medical practices. It was set in an area of the city being revitalized, and business was slow to catch on. Northwestern’s financial leadership decided suddenly to sell the clinic–to the DC who was running it.

What was probably the most significant effort, though, was the Woodwinds Natural Care Center. When HealthEast Care Systems sought to open a new hospital at the lower end of its geographic service area, surveys of the population indicated that they wanted integrative (complementary/alternative) providers. For many months staff from HealthEast, Northwestern, Children’s Hospitals and Clinics and the University of Minnesota’s Center for Spirituality and Healing met to design the ‘optimal clinic.’ With the hospital’s accreditation at stake over the novel arrangement, Northwestern was given the opportunity to open the clinic on its own as a prime tenant, right off the hospital’s entrance. Working with physician leadership, strong relationships were built with the multi-specialty medical clinic in the lower level of the adjacent medical office building, and in the clinic’s first year of operations over fifty per cent of the clinic’s new patients were from medical referrals–an unheard-of achievement at the time. Staffed by doctors of chiropractic and naturopathic medicine, other clinicians included acupuncturists and massage therapists.

The school established other relationships and clinical experiments over ensuing years with a broadening focus on utilization of acupuncture and massage therapy (less polarizing for medical staff than chiropractic). But the Woodwinds Natural Care Center was arguably the most ground-breaking effort. All five locations served as training sites for student interns from Northwestern–an unparalleled set of experiences for student providers.

The Woodwinds clinic was always a financial challenge, unfortunately. A victim of high costs and the low provider compensation that most non-medical providers suffer from, the school recently decided to release the prime real estate position at the hospital and move the clinic. Changing course further, it sold the clinic–to the doctor of chiropractic who has worked there and led its chiropractic efforts for more than a decade. It will be reconfigured and moved a few blocks away, preserving the same clinical services it has offered for years.

Does integration matter to Northwestern? I’m sure leadership will assert that it does, but at this point it isn’t clear to outsiders what the University’s vision of integrative health may be. Limits on resources can impose uncomfortable–even regrettable–choices. But it’s hard to look at the loss of this signature clinical experiment–still unique nationally–as a net gain.

Does integration matter to the marketplace? From consumer/patients’ perspective–the end users–it seems to. Having multiple providers housed or separately coordinated together is convenient for some, less so for others. What we don’t know right now is whether these forms of integration will be viable businesses and clinical models as the retail health care marketplace matures over the next several years. As consumers pay more and more out of their own pockets, employers pull back more from managing benefit purchase options, and awareness grows that value (outcomes over costs) is more appropriate to pay for than simply a volume of services where the risk is essentially borne by the consumer, what form(s) of integration will matter? It’s hard to imagine that Dr. Allenburg’s original vision won’t be vindicated.

What’s lamentable about Northwestern’s lack of achievements in the last fifteen years in this area is really the mounting missed opportunity costs. With its new leadership in place, it may be more prepared to make changes and achieve some of the promise that the last three presidents have either not cared about, not been aware of, or simply not understood. Whether any steps taken at this point will result in a viable, market-facing vision of integrative health care remains to be seen.

The hope here is that new efforts in modeling integration will provide experiences for the school’s students that fully prepare them to function in a health care marketplace where ‘integration’ is more and more driven by consumers’ own preferences and actions and less by what the ‘supply side’ of the system has been able to design. But that requires a type of design thinking and reverse engineering that is challenging for nearly anyone who’s been part of higher or professional education–no matter what its form may have been or how open they think they are. The legacy of that paradigm is deeply entrenched, and its self-interest can trump innovation in many ways; a large herd of those sacred cows roam the streets of educational institutions.

I think there is are five basic precepts that can serve as a functional guide to efforts in this area. In my view, any design must be tested back against the market forces and trends listed several paragraphs above:

  1. The basis (clinical paradigm) for integrative health care needs to focus on value, not volume: outcomes for health problems or conditions are what people want to pay for, anyway. How those outcomes are described, anticipated, promised or assured will affect consumers’ choices.
  2. A derivative precept is that integrative providers are likely going to need to be very disciplined in what their focused, clinical contributions are. Consumers are not going to be able to afford–or tolerate, from a retail consumer perspective–open-ended therapeutic care trials without some real definition on what the most important contributions are from each type of provider.
  3. Management of the costs of care (and payment options) will be enormously important. With consumers paying first dollar coverage out of pocket, how providers, clinics and systems make that care affordable will be critical–and it’s not likely to be tolerated if it’s based on a service volume model instead of outcomes.
  4. With employers limiting benefit option choices less and less and online shopping comparison sites for health care poised to take off, how integrative services are packaged and presented to consumers in private health exchanges will be important for business success.
  5. And finally, the form care coordination takes will matter. Is a common EHR required? Is greater involvement and stewardship of individuals’ PHI required with consumers more actively involved? This is an area that is going to emerge as very, very important over the next several years.

Based on what seems to be true at this time, Dr. Allenburg’s vision has not yet been replaced by anything more substantive. We will have to wait and see if NW’s new direction is a good match for the needs and interests of the marketplace–and the school’s own students.

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