In anticipation of federal mandates from the Affordable Care Act (AKA, “Obamacare”), the Oregon Health Authority (OHA) is preparing to develop an integrated healthcare delivery system, with special attention to enrollees of the Oregon Health Plan (OHP) and Medicare. The stated goal of this program (accessible here: CCO Charter) is to create a “health care system where Coordinated Care Organizations (CCOs) are accountable for care management…for each organization’s members.” These CCOs are to be guided by the “Triple Aim”:
1) improve the lifelong health of all Oregonians;
2) improve the quality, availability, and reliability of care; and
3) lower or contain the cost of care.
However the new CCOs are organized, ensuring an adequate primary care workforce will be a critical requirement for success. Primary care providers (PCPs) form the backbone of healthcare, and provide basic healthcare services – including initial assessment and treatment, referral to specialists, prevention counseling, and vaccination. In the last several decades, however, the percentage of physicians entering primary care has steadily declined. The lack of these providers has been directly related to how much less they are reimbursed than MDs and DOs (doctors of osteopathy) that choose to enter specialties (surgery, radiology, anesthesiology).
To help fill the gap, nurse practitioners and physician’s assistants have been trained at higher levels of knowledge and responsibility, and now offer primary care with varying levels of independence. In Oregon, nurse practitioners may practice independently but physician’s assistants are required to have a portion of their charts reviewed by supervising physicians. Regardless of their degree or level of training, all PCPs are expected to recognize situations beyond their scope and training, and to refer to other providers as needed.
Naturopathic physicians are similarly licensed by the state of Oregon to act as independent primary-care providers, and have authority and responsibility to diagnose and treat disease, order lab tests, refer to specialists, prescribe pharmaceuticals, and administer vaccinations. In addition, NDs have significant training in evidence-based botanical medicine, mind-body interactions, nutrition, and physical medicine that few MDs, nurse practitioners, or physician’s assistants have ever been exposed to. Training is a 4-year program, and requires all of the same pre-medical sciences that MDs and DOs take before starting their programs.
Recognizing the training NDs have undergone, the state of Oregon gives NDs broad authority and responsibility to practice independently.
Currently, the Oregon Health Authority credentials naturopathic physicians to act as primary care physicians through the Oregon Health Plan’s “Open Card” program. In most counties, however, the Oregon Health Plan is administered through local managed-care organizations. Despite ND’s legal authority and the recognition of the Oregon Health Authority, most of these local managed-care plans do not cover NDs in any capacity.
There is some logic to this resistance – most NDs offer therapies that are outside mainstream medical thought. Whether these therapies have evidence to support their use, have fewer side effects, or are less expensive, it is understandable that publicly-funded health plans might be reticent to cover such “alternative” therapies. Naturopathic doctors are also trained and licensed to provide “conventional care,” and naturopathic licenses hold NDs legally responsible for the patients that seek care. If somebody has a urinary tract infection and cranberry juice hasn’t solved the problem, NDs will call in the prescription for an antibiotic.
And what about those “alternative” therapies that NDs are so (in)famous for? Debate certainly rages about the validity of many approaches, especially more esoteric approaches such as homeopathy and acupuncture, but when researchers have asked “real-world” questions about how NDs perform when managing patients (which is really where the rubber hits the road), results are almost uniformly positive – and include tremendous cost-savings. A 2010 study conducted by researchers affiliated with the University of Washington, found that patients using alternative therapies for such common conditions as fibromyalgia, menopause, and back pain spent up to $1410 less on healthcare for their conditions than on patients that didn’t use alternative therapies.
Several studies conducted by the Canadian College of Naturopathic Medicine and sponsored by the Canadian Postal Service have found that postal employees offered care by naturopathic doctors had comparable costs when working with an MD, but frequently had greater productivity at work and fewer side effects from conventional pharmaceuticals. Conditions studied so far have included rotator cuff problems, back pain, anxiety, and heart disease risk factors (blood pressure and high cholesterol) – all very common conditions seen in primary care.
Naturopathic physicians have the numbers to play a significant role in helping to alleviate the primary-care shortage. There are presently about 700 naturopathic physicians licensed in Oregon, and 22 in Lane County alone (most of those 22 are doing primary care in one form or another). The naturopathic college in Portland graduates about 80 new NDs each year – approximately the same number of primary-care MDs that graduate from OHSU. With increased opportunities to offer care within the state of Oregon, many NDs that would otherwise leave will be more likely to stay within the state.
There would be other benefits to incorporating NDs into the new Coordinated Care Organizations. It would become easier to share ideas and knowledge with other providers already firmly ensconced within the conventional medical world. Best practices from the realm of “alternative” medicine will have a better chance of saving the system money. Most importantly, the goal is to see patients living healthier lives.
On Wednesday, October 12, from 6-8pm at Campbell Senior Center (155 High Street), the Oregon Health Authority is seeking input from citizens in Eugene and surrounding areas about the future of publicly-funded healthcare in Oregon. Give your support to the inclusion of NDs as primary-care providers in the new system.
– Bill Walter ND
In addition to his private practice at Golden Apple, Dr. Walter works with Lane County Community Health and HIV Alliance to provide wound care to underserved individuals on the streets of Lane County.