Achieving BETTER OUTCOMES at LOWER COST with NATUROPATHIC MEDICINE Jill Sanders, ND Dean of Clinical Operations

1. Achieving BETTER OUTCOMES at LOWER COST with NATUROPATHIC MEDICINE Jill Sanders, ND Dean of Clinical Operations NCNM acknowledges the OANP for its contributions to this presentation.

2. Why are we here? ND’s offer cost-effective ways of preventing and managing chronic disease MCO’s credential only a handful of NDs. Oregon has a pool of trained PCP’s that are dramatically underutilized - in large part because of insurance policies that are out-of-step with market demands and needs.

3. Community Demand 1. “Oregon Health Authority and Oregon Health Policy Board September 2010 Community Meetings,” Submitted by Oregon Consensus, Portland State University, 10/4/10. Every public meeting conducted by OHA for comments on CCO transformation included demand to include naturopathic care. Every public meeting conducted by OHA in 2010 for comments on health insurance exchange included demand to include naturopathic care.1

4. Licensed Naturopathic Doctors • NDs are primary care providers (PCPs) who: • Specialize in the prevention of illness, as well as the management of chronic disease • Trained in both natural and conventional evidence-based medicine and experts in drug-drug, drug-herb, and drug-nutrient interactions • Use conventional diagnostics and standards to diagnose and treat illnesses and health conditions • Treatments include:a variety of natural therapies including diet and nutrient therapies, counseling, botanical medicine, lifestyle changes, patient accountability, and conventional therapies such as pharmaceutical medications.

5. ND Education • Four-year accredited, graduate-level naturopathic medical school • U.S. Department of Education and the Carnegie Institute classify the ND degree as a First-Professional Degree under Doctorate-Professional (Clinical), on par with MD and DO • Council of Naturopathic Medical Education (CNME) is a programmatic accrediting agency recognized by the U.S. Department of Education • Required to pass National Licensing Exam • Naturopathic Physicians Licensing Examination (NPLEX) • Basic Sciences and Clinical Boards • Qualify for federal Stafford Loans: ND students graduating with $150,000 - $250,000 educational debt.

6. ND Education

7. Residencies • Residencies are currently available for 1, 2, or 3 years • All are privately funded • Residency sites range from private clinics, to community FQHC clinics, to in-patient hospitals (Cancer Treatment Centers of America) • Expanding but not available for every graduate • Majority are for primary care

8. In Oregon, Licensed NDs can: • Diagnose, prevent, and treat disease • Perform physical exams including orificial exams (oral, vaginal, anal) • Order x-rays, electrocardiograms, ultrasound, CT, MRIs, and laboratory tests • Draw blood and perform CLIA-waived lab tests in-office • Perform minor surgery • Deliver babies (with additional certification) • Provide injections including vaccinations and IV medications • Prescribe all natural & pharmaceutical medications needed in a primary care setting • Are eligible for Drug Enforcement Agency (DEA) numbers for Schedules II-V (authority to prescribe controlled medications)

9. Standards of Care • Taught conventional standards of care at NCNM • Held to conventional standards of care in court of law • Recognize all same standards of care when it comes to testing, diagnostics and metrics • Primary Difference: • Treatment selected based on whole-patient functional approach vs. symptomatic approach • Getting from Point A to Point B might look a little different, but outcomes often better, cheaper to obtain and with greater patient satisfaction (side benefits vs. side effects)

10. Billing & Reimbursement • Hold seat on AMA Current Procedural Terminology Editorial Panel/Health Care Professional Advisory Committee • Use same CPT, ICD-9 Codes and HCFAs • Credentialed as PCP by some insurance plans & as “alternative” by others

11. NDs Serving Medicaid, Uninsured or Underinsured • Credentialed as PCPs by Oregon’s Department of Medical Assistance Programs for Fee-for-Service population • Some Managed Care Organizations credential NDs with very narrow parameters (i.e., only if working in FQHC) • NDs successfully integrated in (short list):

12. Donated Services • NCNM provides 16,220 visits annually at FQHC community health clinics (9,077 ND, 7,146 LAc) and is a member of the Coalition of Community Healthcare Clinics.

13. The Most Underutilized Primary Care Workforce • State-wide capacity • 720 active licensed in Oregon • ~641 (89%) estimated to practice primary care • ~500 (70%) are working at less than 80% capacity • ~547 (76%) of NDs surveyed indicated they would apply to get credentialed with CCO to see OHP if they could • Tri-county capacity • 426 active licensed in tri-county area • ~379 (89%) estimated to practice primary care • ~285 (67%) are working at less than 80% capacity • ~311 (73%) of tri-county NDs surveyed said they would apply to get credentialed with CCO to see OHP if they could

14. Capacity

15. Addressing the PCP Shortage Remove all barriers to insurance coverage and Oregon could increase its PCP workforce by 15% immediately*. Naturopathic physicians are the fastest-growing segment of the full-scope primary care workforce. ND medical schools graduate 500 NDs each year. *adding 640 ND PCPs into the pool of 4,112 family medicine, general internal medicine, general practice, pediatrics, geriatrics and adolescent medicine MD/DOs. Oregon Health Professions: Occupational and County Profiles, Office for Oregon Health Policy & Research (Oregon Health Authority), April 2011, p. 64)

16. Oregon Has a Vested Interest in Covering Naturopathic Physicians • Cost-Effective • A Solution to Primary Care Shortage • Community Demand

17. NDs Prevent Chronic Disease and Decrease Health Costs • NDs are the only PCP’s trained extensively in counseling, nutrition, exercise, prescriptions, and stress management to specifically address the prevention and early intervention of chronic diseases • In Washington, naturopathic care was projected to result in up to 40% reduced cost for chronic and stress-related illness, as well as 30% cut in specialist utilization1, leading to Blue Shield’s voluntary decision to credential NDs as PCP 1. Henry. 1995. King County Medical Blue Shield Phase 1 Final Report: Alternative Healthcare Project Steering Committee. August 5, 1995.

18. Outcomes & Metrics • Central City Concern’s Old Town Clinic reports that the NDs on their staff “perform just as well as, and in some metrics out-perform, MD internists” in all metrics. – Rachel Solotaroff, MD, Medical Director, Old Town Clinic • A naturopathic clinic was a top scorer in all categories of patient experience, an important metric in improving health.1 1. Your Voice Matters: Patient Experience with Primary Care Providers in the Puget Sound Region, 2012 Community Checkup Overview, conducted by Puget Sound Health Alliance. www.WACommunityCheckup.org

19. Cost-Savingsof Naturopathic Medicine • Finding efficiencies for insurers • Decreased use of pharmaceuticals • Decreased use of specialists • Examples of cost reductions

20. Evidence of Cost-SavingsWashington “With respect to naturopathy…59% of [users] reported decreased visits to [MD] primary care physicians, and about 48% reported decreased visits to specialists. And then another major driver of health care costs: over 50% reported decreased use of prescription medications.” – Laura Patton, MD, Medical Director of Alternative Services at Group Health Cooperative, Washington State (in testimony before the Vermont House Health Committee, March 3, 2005)

21. Evidence of Cost-SavingsOntario1 In a 2011 survey of Ontarians who use naturopathic doctors: • 28% report use of prescription medicine was significantly or noticeably reduced • 19% report reduced visits to the hospital • 18% report reduced use of expensive medical specialists The survey also found: • 57% of Ontarians believe naturopathic medicine is leading to better health outcomes for those who use it 1. Attitudes Toward Naturopathic Medicine. Innovative Research Group. September 1, 2011. www.innovativeresearch.ca, http://www.ccnm.edu/ontarians_say

22. Evidence of Cost-SavingsVermont1 • VADA (Vermont Auto Dealer’s Association) wellness program administered by NDs: • saved nearly $1.5 million in medical costs the first year they made Naturopathic Medicine available to its members. • Saved $1,800 per employee. • Produced a return on investment of $21 for every $1 spent in direct & indirect costs. • Only 0.2% increase in per member claims costs (2005) compared to national average of 7%. • Each VADA-identified health risk showed improvement over two years (chart). • RiskReduction • Hypertension 36% • Cardiovascular risks 35% • High cholesterol 16% • Physical inactivity 21% • Smoking 17% • Excessive stress 25% 1. Vermont Automobile Dealer’s Association and Green Mountain Wellness Solutions http://www.greenmountainwellness.com/ ; http://www.vermontada.org/wellness.asp

23. Summary of Studies • Improved outcomes in all of the 13 clinical studies meeting systematic review criteria • Benefits for conditions ranging from intractable pain and disability to epidemic chronic diseases • Significant employer, participant, and societal savings in cost-effect analyses 

24. True Primary Care • 67.7% of patients in WA State who receive Naturopathic care do not receive concurrent care from an MD/DO for their RFV (reason for visit); Naturopathic care is not “add-on” medical care in most cases.1 1. Cherkin DC, Deyo RA, Sherman KJ et al. Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. J Am Board FamPract. 2002;15:463-472.

25. Legal Requirements of Insurers Affordable Care Act, Section 2706 (a) Providers- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.(b) Individuals- The provisions of section 1558 of the Patient Protection and Affordable Care Act (relating to non-discrimination) shall apply with respect to a group health plan or health insurance issuer offering group or individual health insurance coverage.

26. What Do Patients Need? • Integration of naturopathic physicians into CCOs (& all insurance) to meet the primary care needs of Oregon • Removal of credentialing barriers currently imposed on NDs • Coverage of the SAME services that are provided, regardless of whether provided by naturopathic doctors, medical doctors, osteopathic doctors, nurse practitioners and physician’s assistants

27. Common Insurance Pitfalls to Avoid Many private policies create barriers to care that drive up costs, including policies that: • Refuse to cover prescriptions or vaccinations from NDs. • Refuse to cover labs or diagnostic images ordered by NDs. • Place arbitrary annual caps – often $1,500 or less – on services rendered by an ND. Sometimes labs and diagnostic images are applied toward this cap. • Provide “illusory benefit” to achieve market advantage – i.e., saying they’ll cover services for a migraine, but not a pap smear. • These policies force many to duplicate their office visit with an MD, DO, or NP to get the same test, prescription or lab ordered…and drives up healthcare costs

28. Questions?