Alternative, Conventional Care Forge Uneasy Alliance

Driven by consumers disenchanted with modern medicine and zealous entrepreneurs who envision a hugely lucrative market, the alternative medicine movement has experienced explosive growth.

Across the country, dozens of hospitals, many of them cash-strapped, are rushing to open alternative medicine programs--often despite an acknowledged shortage of qualified staff and without guidelines for providing services that are, by definition, experimental.

Insurers and health maintenance organizations, seeking to appeal to customers with treatments that are frequently low in cost, have plunged in as well.

But in the rush to meet the demand for different types of health care, corners are being cut and safeguards ignored, an extensive Times investigation has shown.

For example, while insurers often refuse to pay for health care that is considered “experimental” or unproven, in the case of alternative medicine, the standard often appears to be lower.

“Some people are proceeding cautiously. But alternative medicine has become a huge industry, and there are a lot of people wanting a piece of the pie,” said Michael Cohen, a professor of law at Chapman University in Orange and the author of a new legal guide on alternative health care.

Moving Ahead Despite Concerns

For now, at least, the marriage of alternative and conventional health care is stumbling forward on a shaky scientific foundation that requires consumers to make important decisions about their medical treatment with often unreliable information.

As for conventional medical practitioners who could have an impact in shaping the trend in perhaps a more deliberate manner, they often feel ineffectual. Many say they can neither endorse nor resist alternative medicine because it encompasses such a baffling spectrum of therapies and therapists--from promising to ridiculous.

“This is a big experiment,” said Dr. Steven Rosenblatt, a Los Angeles physician, acupuncturist and alternative health care consultant.

“It’s not an experiment fraught with a big downside. But . . . being forewarned that this is an experiment, you need to take extra steps and extra precautions.”

“I think there will be a lot of stupid, crazy things that will go on in the name of holistic-complementary-alternative medicine that are going to work against integration,” warns Dr. Andrew Weil, the well-known author of books on alternative health who asserts that MDs should be shepherding the movement.

The often slapdash way the movement has spread can be seen in many recent developments:

* California regulators ruled earlier this year that any HMO that wanted to offer acupuncture benefits to its members would be required to also include Chinese herbal therapies. HMO officials protested loudly that the decision lacked scientific merit. In late July, the California Department of Corporations, which regulates HMOs in the state, abruptly reversed its decision after complaints from some health plans and inquiries from The Times.

* Doctors have signed on with multilevel marketing networks to hawk dietary supplements out of their offices--often to make up for income lost to managed care. The practice has been challenged by some critics as neither good nor ethical medicine.

* With highly qualified acupuncturists and naturopaths in short supply, some insurers, in their haste to get new “products” to market, are hiring people with shaky credentials, critics charge.

“There are networks that take practitioners who will work out of the back seat of a car,” said Marla Orth, CEO of Landmark Health Care, a California managed care firm specializing in alternative therapies.

* Hospitals, likewise, are racing ahead, seeking to market the attractive prospect of integrating alternative and traditional medical practices.

Many hospitals are opening only small units or have given one or two staff doctors permission to offer alternative treatments.

“Some hospitals are doing this with their fingers crossed,” said Dr. John Renner, a critic of alternative medicine and director of the Consumer Health Information Research Institute in Independence, Mo.

“I think the hospitals will go through a learning curve and some will find, ‘Maybe this isn’t as romantic as I thought it would be.’ ”

The going isn’t easy for any institution taking the lead in integration. Cedars-Sinai Medical Center opened its Integrative Medicine Program recently after a year of false starts, missteps and turmoil.

After publicly announcing the program’s debut, the program went dark for nine months; the consultant hired to launch the program left in a dispute with the hospital over issues of control; a search for a new director with the right qualifications dragged on for months, and several staff meetings degenerated into bitter debates about the merits of establishing such a program at Cedars.

Cedars’ program will have three components: a clinical arm (95% of the services will be outpatient), an educational arm for staff, and a fellowship in alternative medicine. The program will emphasize research and evidence--skills at which Western medicine excels, said Dr. Glenn Braunstein, chairman of Cedars’ Department of Medicine.

“There is no question that there are people who think this is the wrong way to go,” said Braunstein. “Why would Cedars-Sinai . . . jump on the bandwagon and do alternative therapy? Is this just for the money? My response is that the public wants this, insurance wants this and, yes, there is a market.”

The health industry is eyeing big profits from integrating alternative and traditional medical services for two major reasons.

First is consumer demand. Daniel Freeman Hospital, for example, began providing acupuncture for treatment of pain last year. Thus far, only one patient among 51 has turned down the treatment.

“Our expectations have been greatly exceeded,” said Nancy Carlson, chief executive of the South-Central L.A. hospital. “I’ve been amazed at patients’ eagerness to try this. We’re now considering a broader program to offer acupuncture in our outpatient clinics.”

A second reason is cost. One survey of managed care providers offering alternative services in Washington state found that 55% of patients who used alternative treatments said they reduced their use of conventional care. And 61% said they reduced their reliance on prescription drugs. The study will be published in a special edition of the Journal of the American Medical Assn. later this year.

“The goal is to make sure you get the best possible care you need at the lowest possible cost,” said Wayne Simon, a Century City attorney who specializes in health care. “This movement addresses that.”

“It’s simply because of popular demand,” said Dr. Shri K. Mishra, a USC neurologist and expert in ayurvedic medicine. “There is money to be made.”

Unfortunately, Mishra adds, neither the economic savings nor evidence that alternative care can be superior to standard care have been established.

“Integrative medicine has become a big money-making machine,” Mishra says. “But I’m afraid it will backfire. We have to do more research and back these things up scientifically.”

But professionals like Mishra aren’t calling the shots; consumers and business executives are.

For instance, voters in Washington state in 1995 passed legislation requiring HMOs to cover any licensed practitioner in the state--including naturopaths, acupuncturists and massage therapists.

The legislation was challenged by insurers and organized medicine in court and blocked for three years (an appeals court voted to uphold it in June).

But even while the mandate was legally in limbo, “No health plan stepped back and said, ‘We won’t cover this,’ ” said Darrell Stewart, president of Alternare, an alternative care provider in Seattle. Alternative practices have “got a solid foundation in the culture here.”

Only now are studies underway in Washington to look at such crucial issues as whether alternative care coverage has improved patient health, cut costs or reduced reliance on prescription drugs.

Chinese Herbs Focus of Conflict

Perhaps no situation more aptly illustrates the tumbledown manner in which alternative medicine is going mainstream than the fight within California over Chinese herbs.

Fittingly, perhaps, the conflict began in the Silicon Valley, the land of full-throttle, high-stress workplace cultures. Acting on requests from electronics firms that said alternative therapies were popular with workers, Lifeguard, a small HMO, announced it would offer acupuncture as a benefit to members.

The request seemed reasonable enough. Studies, including a 1994 government document, lent support for several therapeutic uses of acupuncture. Lifeguard made plans to roll out its acupuncture benefit by summer of 1997--one of the first health plans in the country to do so.

But when the company applied to state regulators for a required license, it was dumbstruck by the state’s response. If Lifeguard wanted to offer acupuncture to its members, state regulators said, it would also have to offer a maximum $1,000 annual benefit for Chinese herbs.

The state’s reasoning?

“Herbal therapy is an integral part of the overall treatment of patients with acupuncture or Chinese or Eastern medicine and the main thrust of such traditions,” Linda D. Azzolina, a lawyer for the California Department of Corporations, which regulates HMOs, wrote in a letter to Lifeguard last December.

Lifeguard, however, didn’t want any part of Chinese herbal therapy. Joseph Aita, Lifeguard’s medical director, said he had serious safety concerns about Chinese herbs and the fact that they are not regulated by the Food and Drug Administration for safety and effectiveness, as are drugs. Indeed, in at least one case, a Lifeguard patient suffered serious kidney damage after ingesting herbs. “It scared the heck out of me,” Aita says.

Lifeguard loudly protested the state requirement, but the regulators stuck to their position. In April, Warren Barnes, the chief attorney for the corporations department, said in an interview that the HMO did not even have an argument to make. “I don’t see an issue here, frankly,” he declared.

Barnes said the department had based its decision on the recommendation of an outside consultant whom he declined, as a matter of agency policy, to identify, except to describe the person as both a medical doctor and licensed acupuncturist.

In July, the department suddenly changed its mind. But the decision apparently had little to do with science.

Julie Stewart, a department spokesman, said the agency’s about-face was the result of a legal interpretation: Because state law doesn’t require HMOs to provide prescription drugs as part of a standard medical benefit, it seemed improper to require herbs, which can have drug-like effects, as part of an acupuncture benefit.

Despite such confusion, health care providers are adding alternative benefits posthaste. A survey by Stanford researcher Kenneth Pelletier found that 30 major insurers are now covering more than one form of alternative medicine.

Obtaining alternative health treatments within a managed care setting does provide some potential benefits to consumers. Currently, for example, many consumers are accustomed to paying cash to a “healer” practicing in a dubious setting and with no state license or connection to a major medical establishment.

Under managed care contracts, alternative care providers will have to meet National Committee on Quality Assurance standards that include credentialing requirements, submitting to inspections and grievance procedures, abiding by record-keeping guidelines, office safety codes and company fee structures.

Theoretically, at least.

Culture Clashes Inevitable

The fact is that many alternative practitioners have a long way to go to live up to the rigid protocols of Western medicine. And they’re not even sure they want to.

When he was offered the chance to join a managed care organization last year, David Chen, a Whittier acupuncturist, demurred.

“Why do I need managed care?” he asks.

“In the past, acupuncture practitioners were out there by themselves--no one would cover this. We are aggravated because we always get the very desperate patients, and yet we survived,” he says, adding that managed care will lower his fees and increase his paperwork.

“Complementary providers are very autonomous,” says Douglas Metz, a chiropractor and vice president of American Specialty Health Plans. “They don’t want to play by the rules. Some feel that accountability will dilute the effectiveness of their treatment methods. They say, ‘If you try to change the treatment method too much, it won’t work.’ ”

Much like traditional doctors, acupuncturists, for example, chafe at being told by an HMO that a particular condition, such as headaches, should require a specific number of treatments at specific intervals and should not include herbal remedies.

But insurers appear to have good reason to keep tight reins on this new classification of healers. Alternative practitioners often aren’t trained to handle medical emergencies and may not have malpractice insurance coverage or hospital privileges. Their offices may even lack basic business equipment.

And then there are the intangible problems inherent in the integration of alternative and Western care. As they share patients, both the alternative practitioners and their Western cohorts will have to find ways to communicate about medical problems that each approaches from a different perspective.

If the integration of alternative, ancient or foreign healing systems was easy, perhaps it would have been accomplished with ease long ago. Instead, however, American medical doctors have a long tradition of looking down their noses at alternative practitioners.

The American Medical Assn. in 1966 went so far as to adopt a resolution forbidding its members to refer patients or otherwise “associate” with chiropractors. That launched a legal feud that wasn’t resolved until 1990, when the AMA dropped its fight with chiropractors.

Today, however, there is a distinct feeling in the air that if you can’t beat ‘em, join ‘em.

At a conference earlier this year in San Diego, Dr. David E. Eisenberg, the Harvard-based author of the pivotal 1993 report on Americans’ interest in alternative care, urged his colleagues to get with the program--like it or not.

“Ask your patients if they are using alternative care,” he told them. “The odds are one in four they will say yes. . . . We are going to be left out--those of us who are MDs and wear white coats--if we don’t realize this is part and parcel of the real world.”

But others are highly critical of colleagues who abandon the scientific high ground.

“Honesty and integrity of information is the thing that will be lost the most if doctors say, ‘Go ahead and take this, it probably won’t hurt you,’ ” warns Renner.

“Someone has to help patients understand priority. Everything doesn’t work. Everything isn’t uncontaminated. Everything isn’t going to not interact with the other drugs you’re taking. Patients can’t lose trust in the people who are giving them health advice.”

Many of the conflicts can be seen in the experience of Minneapolis businessman Rick Krieger. In late 1996, with Americans’ fascination with alternative medicine growing, Krieger opened the Newbridge Wellness Center on the edge of a tony shopping district in the posh Minneapolis suburb of Edina.

The $575,000 health clinic was to be an ambitious model for integrative care. Resplendent with plush carpets, a tea-and-juice bar, massage chairs and a health-goods boutique, it was to be the flagship in a nationwide chain.

Then the problems began. Arguments arose over who was in charge of the patient--the alternative practitioner or the referring doctor.

“The physicians didn’t want to work with the alternative practitioners. And the alternative practitioners were uncomfortable with the MDs telling them what their qualifications were,” says Krieger, a Minneapolis venture capitalist.

Concerns over the lack of scientific support for many alternative treatments eventually caused the clinic management to limit services to three areas: chiropractic, massage and acupuncture for pain management and stress relief.

But then there were issues over how to limit the number of treatments covered by insurance. “If you don’t restrict it, you go out of business. Everyone would love to have a massage once a week,” says Krieger.

Ultimately, cash-flow problems forced the clinic’s closure.

“It’s a very, very complex area,” sighs Krieger. “I believe alternative medicine has to position itself as a therapeutic rehabilitative service. Western medicine will accept that. But when they try to position it as a curative service, that’s a problem. The science isn’t there.”

The series, “Alternative Medicine: The $18-Billion Experiment,” is available on The Times’ Web site at: https://www.latimes.com/altmed. To purchase reprints, call Times on Demand, (800) 788-8804.

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About This Series

Sunday--Growing at an astonishing rate, the alternative medicine movement has moved into the mainstream. But do these treatments work?

Monday--Independent laboratory tests raise questions about whether herbal supplements live up to their advertised potency.

Plus--Alternative practices: what are they, how do they work? In the Health section.

Tuesday--How Utah has become the headquarters of the nation’s herbal supplement business.

Today--HMOs and hospitals are jumping onto the alternative medicine trend but often are cutting corners as they do so, experts warn.

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Two Approaches to Curing an Earache

Both alternative and conventional medical practitioners must be able to communicate if health care is to become truly “integrative.” However, each system has dramatically different philosophies and languages, as this graphic on treating an ear infection demonstrates.

Conventional Medicine

DIAGNOSIS: Otitis media

CAUSE: Bacterial or viral infections cause inflammation and blockage of eustachian tube, which results in pain and accumulation of fluids in middle ear.

TREATMENT

* Antibiotics (10 days)

* Acetaminophen or prescription eardrops for pain

* Decongestant, such as pseudoephedrine

****

FOLLOW-UP

* Recheck in two weeks. If problem persists, another course of antibiotics.

* A 1987 study found that children given antibiotics did not improve any more than children not given antibiotics.

****

Traditional Chinese Medicine

DIAGNOSIS: Catarrh of the ear (also: er ting or er liu)

CAUSE: A diet too high in mucus-forming foods such as fatty foods, refined grains and sugar, lack of vegetables and mineral-rich foods. Immune system is depressed because of diet, allowing invaders.

TREATMENT

* Citrus seed extract, considered a potent natural antibiotic (three or four drops of concentrate in water, three times a day for 10 days).

* Tea tree oil drops in ears to counter infection and stimulate immune system.

* Acupuncture treatments to redirect Jing Qi energy flow along surface of the body and correct the electrical imbalance. This is the body’s first line of defense against external, disease-causing influences.

* Improve diet by adding vegetables and fruits, such as carrots, citrus, onions; avoid dairy, wheat, oils, sugar and refined foods.

* There are no substantial studies on the safety or effectiveness of traditional Chinese medicine in the treatment of middle ear infection.

* Some combination MD-TCM doctors would also give antibiotic to kill bacteria as first step.

EARDRUM

MIDDLE EAR

Triple warmer

meridian

Kidney

meridian

Site of blockage

EUSTACHIAN TUBE