The idea of using the altogether too loosely defined set of CAM solutions in treating the sick has been a contentious one for as long as I have been involved in health care.  Our family was an osteopath when I was growing up, when even that was a kind of “alternative” approach to medicine, though it has been largely incorporated in traditional medicine today.  I have on occasion tried acupuncture and chiropractic, without becoming a convert to CAM as “the” alternative.

With the growth of interest and investment in proactive health management (PHM) applied to individuals and populations, in private practice, worksites, retail clinics, employee and insured populations, is opening up a significant new opportunity for “complementary and alternative medicine”, however it is defined.  Included among what some define as CAM are the use of “nutriceuticals” whose use has been scientifically supported, such as folic acid for pregnancy, along with stress management coaching, for example for general risk reduction.

The determination of whether and which CAM solutions will be covered by insurance, incorporated into traditional medical practice or “integrative medicine” programs, etc. has largely been a function of four different avenues: political, scientific, popular, and economic.  As CAM penetrates the PHM market, it is likely that the economic and market avenues will dominate, though the political and scientific will continue to play a role.

The political route has been used by a number of CAM practitioners and their supporters, with noisy protests, effective lobbying, etc. leading to mandates for coverage in state legislatures, and by Medicare or Medicaid at the federal level as well.  In a country where freedom of choice is such a mantra, it is difficult to argue against people having the right to choose CAM therapies and individual practitioners whose efficacy and safety may not yet have been proven.  And when they cost less than traditional medicine, it becomes that much harder.

The scientific route is increasingly being used in recent years, as studies are finally being done in keeping with traditional standards of rigor, though many CAM therapies are difficult to compare to a meaningful “placebo”.  What is the “inert” alternative to chiropractic, for example, or even acupuncture that would compare to the sugar pill that can be used in pharmaceutical trials?  And Chinese medicine, for example, leans toward total customization for the individual patient, so there is no clear single alternative that can even be compared to a single placebo.

Moreover, there is the question as to whether the placebo effect should be discounted in CAM studies.  Since this same affect often plays a significant part in pharmaceutical and medical care success, the overall effect should arguably be recognized, rather than just the demonstrable difference that the therapy makes alone.  If this effect is stronger in CAM, as it seems to be in many cases, particularly in treating chronic pain, then why discount or ignore it?

The market has long been a major factor in promoting acceptance of CAM, particularly when few scientific studies were being performed.  When more than 30 or 40% of consumers use CAM practitioners or treatments of some kind at least some of the time, the voice and wealth of consumers can support such solutions even if insurers and traditional medicine refuses to.  And if physicians wish their patients to inform them about CAM solutions they are using, as part of coordinating care and avoiding contra-indicated mixing of the two, they must at least be willing to discuss the idea with patients.

As consumers have an increasing share of the healthcare burden imposed upon them, they may more frequently seek care from CAM providers whose prices tend to be significantly lower than those of physicians.  The very transparency that is being espoused so reluctantly by traditional providers about their prices will tend to make it easier for consumers and payors alike to identify which are the most cost-effective providers of sickness care, and consumers may have different notions about which effects they think most important than do traditional providers.

The potential that CAM solutions and practitioners can protect and improve the health of consumers with as much success as do traditional providers seems very real.  For one thing, most CAM providers do not command the same income as do physicians, so their services need not cost as much.  For another, having been forced most of the time to live without any, or with limited insurance coverage, CAM practitioners often operate with nowhere near as high an overhead practice costs as do physicians.

And if employers, insurers, and government payors are persuaded that CAM strategies for protecting and improving the health of consumers can achieve the desired cost savings they not only wish for but feel are essential for survival, there should be a far more open mind about CAM in health management than there has been in sickness care.  While arguments over the safety of some CAM therapies will no doubt continue, if they do no harm, and end up saving payors more money than traditional providers do, it seems likely that they will be even more widely accepted, by payors as well as consumers.

I expect to see some major disruptions in the health management market, as the four avenues are used simultaneously in the health as well as the sickness domain.  It should be very interesting.