Via Bhushan Patwardhan, PhD, an editorial board member at JACM-Paradigm, Practice and Policy Advancing Integrative Health (The Journal of Alternative and Complementary Medicine), I was invited to write a backgrounder and participate in an October 8, 2020 presentation to the “Committee on Formulation of Integrative Health Policy” of India’s National Institution for Transforming India (NITI Aayog). Aayog is a Hindi term for “policy commission.”  I was introduced to the Committee by Vinod Paul, MD, who heads up the Health and Nutrition “verticals” for the NITI Aayog. The policy commission is developing directions across a range of India’s strategic interests. This Committee’s charge is to make recommendations on implementing integrative health country-wide. In my presentation, I chose to focus on 5 Key Factors learned on the ground here. I closed by sharing shared one remarkable model.

Patwardhan, who invited me in, has worked on multiple national policy making committees – Taskforces of National Knowledge Commission, Planning Commission, and the Ministry of AYUSH. The acronym refers to a department that manages policy relative to Ayurveda, Yoga, Unani, Siddha and Homeopathy, and also includes naturopathy. Such a quintet here would be the USA’s licensed chiropractors, acupuncturists, naturopathic doctors, massage therapists, and direct-entry midwives. Patwardhan, the editor in chief of the highly regarded Journal of Ayurveda and Integrative Medicine (J-AIM), presently serves as co-chair of the committee setting a research strategy relative to that nation’s robust interest in the potential contributions of AYUSH methods relative to COVID.

B Patwardhan, Paul, A Patwardhan, Morandi, Weeks

My comments followed those of Antonio Morandi, MD, the president of the Italian Scientific Society for Ayurvedic Medicine, who provided data on integrative medicine in Europe, and Avinash Parwardhan, MD, from the Department and Community and Global Health  and George Mason University. His presentation provided a great deal of useful quantitative guidance that detailed the state of integration in the United States across multiple stakeholders.

I had previously submitted a written report on various activities, and chose to use my limited time in front of the panel to offer the story from inside the work on the ground in the USA integrative effort. Rather than, for instance, merely sharing data points on the level of insurance coverage of complementary and integrative health services, I spoke to the misalignment of incentives that is the why of the lack of coverage. My hope was that the understanding of history and context might inform India’s own challenges in integrating its diverse traditions for its peoples. Here are the “5 Key Factors” I highlighted, and a couple points about each. I’m curious about any of your comments and reflections.

#1 – Setting Standards 

For biomedicine and traditional medicine practitioners to communicate, public health demands clarity on the educational and practice standards of those in each domain. I shared a useful chart from page 9 of the Academic Collaborative for Integrative Health (ACIH) Clinician’s and Educators’ Desk Reference on the Licensed Integrative Health Professions that was based on a chart first assembled on page 17 here. It documents the standard setting of the USA’s five “traditional medicine” professions that have federally recognized accrediting agencies as noted above: chiropractic, naturopathy, acupuncture, massage, and direct entry midwives. I also underscored the importance, on the conventional medicine side, of the development of Fellowships in Integrative Medicine at U Arizona Andrew Weil Center for Integrative Medicine and the Academy for Integrative Health and Medicine, and the American Board of Integrative Medicine that was born out of this activity. These give shape to the mushy term “integrative medical doctor” and have helped conventional organizations identify and hire their internal leaders on integrative projects.  Because education for the USA’s “traditional” practices typically does not include skill training for working in mainstream institutions, I highlighted the competencies on “Evidence-Informed Practice” and “Institutional Healthcare Culture and Practice” from the ACIH’s Competencies for Optimal Practice in Integrated Environments. To speak to the Indian environment, I additionally noted the fine work, if non-traditional, on standards in yoga therapy led by the International Association of Yoga Therapists. I also noted, in contradistinction, the failure thus far of the various factions in the USA Ayurveda community to collaboratively come to standard-setting agreements. While the Committee was quite interested in the osteopathic model, both Avinash Patwardhan and I underscored that the vast majority of osteopaths have left their natural health roots and are fully engaged in the pharmaceutical model.

#2 – Evidence

Here I showed the growth in investment now at $151-million per year at the NIH National Center for Complementary and Integrative Health (NCCIH) – see figure. I followed with a slide that showed that this level is just roughly a third of all the complementary and integrative health research investment of roughly $450-million when all of the NIH centers are taken into consideration. I then dove more deeply into the evidence debate, sharing the important learning that, while organized medicine likes to say it is moved by evidence, we have discovered that while evidence may be necessary, it is certainly not sufficient to change the minds and practices of a medical industry that remains full of ignorance and bias and continues – with an estimated 30%-50% of services over-treatment –  hell-bent on production of services, regardless of whether people need them. I had a moment to briefly allude to the problems of evidence when traditional/non-pharma practices are often multimodal face the reductive biases of the research establishment that prop up pharmaceutical practice. I had a brief moment to share the recent positive development at the NCCIH under director Helene Langevin, MD on exploring research for engaging “whole person health” and the related complexities in the new strategic plan under discussion.

#3 – Collaboration

I acknowledged that I didn’t know how the medical system in India works, then described how here in the USA, where citizen action can make a difference, to collaborate. We have found it helpful, for some advances, to move from individual voices, or an institution’s sole case-making, to consortia of entities in the same field, and eventually to interprofessional and sometimes multi-stakeholder collaborations. With the Committee of the NITI Aayog’s expressed interest in integrative MDs, I shared the growth of the Academic Consortium for Integrative Medicine and Health. I noted its success in shifting the pain guidance in the Joint Commission’s accreditation standards to support more use of non-pharmacologic approaches. I mentioned how the Integrative Health Policy Consortium (IHPC) with its 27 organizations – from MDs to massage therapists and homeopaths – was instrumental in achieving greater inclusion of complementary and integrative in the 2010 Affordable Care Act. I was able to briefly mention the important emergence of AIHM as an interprofessional organization, a big tent, and of Integrative Medicine for the Underserved, that is broadly supported across the integrative health community.

#4 – Motivation/Incentive Alignment

I then got even closer to the heart of the integration dynamic. I was able to briefly speak – and cover in my written backgrounder – the fundamental disincentives to appropriate integration in the USA medical industry. We have an insurance system that benefits, over the long run, from high costs, and a delivery system run by high costs specialists and hospital executives whose idea of success is generating revenues from dominating markets with high-cost specialist services. Then I turned to events that created alignment: 1) the publication in 1993 of the Eisenberg et al study in NEJM that showed a third of adults were using some “unconventional” medicine and billions were being spent out of pocket. Multiple stakeholders began treating the field differently on seeing the dollars, patient-loyalty, and market share; 2) the movement from “volume to value” and the Quadruple Aim, that lifted parallel values to those espoused in the integrative movement; and 3) the crisis in chronic pain management (a.k.a. “opioid crisis”) that led to the mainstream of medicine actually reading the literature on non-pharmacologic approaches and beginning to elevate them in multiple guidelines. These externally-generated alignments illuminated the evidence.

#5 – Relationships, Relationships, Relationships

I spoke to the early and abiding awareness that success of integrative strategies frequently requires internal champions who have established trust relationships in their institutions. Frequently this needs to be from the C-Suites. I mentioned a recent interview with the director of Francoise Adan, MD, the director of the Conner Integrative Health Network associated with Case Western University. Adan shared that 10 years ago they started with perhaps a half dozen MDs referring to them, and now, with time, experience, and familiarity, over 1800 have. I shared my own experience in Washington state with a network of primary care clinics and later with the Office of the Insurance Commissioner on intentional relationship building. Richard Layton, MD and I wrote it up as “Integration as Community Organizing.” Bottom-line: invest in relationships like the medical industry likes to invest in technology. Without relationships, the standards, evidence, shared incentives, and collaborations are virtually worthless.

The Model: Veteran’s Administration

In the very brief time I had left – by going over my time allotment! – I introduced the NITI Aayog Committee on Formulation of Integrative Health Policy to the Whole Health model in development at the USA Veterans Administration. I briefly went through how the VA is better aligned on all 5 of these elements than is civilian health care: incentive alignment via single payer and employed practitioners; ability to require reluctant MDs to learn about integrative health sciences science; the use of and respect for certification and educational standards of the integrative fields; and the investment in an evidence-informed implementation strategy. I noted that the latter is powered by a large research team that is examining the model every which way. While my written backgrounder provided more details, I was able to share that, based on the outcomes in the VA’s multifaceted report released in 2019 and pictured in the figure to the right, the bosses at the VA chose to expand the Whole Health model from 17 to 55 VA medical centers. Nothing in civilian medicine in the USA can wave a candle at that level of adoption.  In a follow-up note to the NITI Aayog Committee, I underscored that if there was anything they had time to explore more deeply, that the VA’s evidence-informed, standards respecting roll-out is where the gold is from the USA experience.

Coda: While I quickly ran through the themes, sadly, the internet connection was not so good. I was told that the core of the message got through. This is as close to a distillation of the key factors for creating appropriate integration as I have ever presented, or written. (I am curious about any or your responses.) Meantime, one cannot shake the burden of seeking to create change in the USA medical model that still must be dragged kicking and screaming toward becoming a system focused on creating health rather. Here the industry thrills to the successful production that leads to massive over-treatment, waste, medical deaths, and dollar costs that are in a category of our own. One wonders what utility these lessons may have for the grossly less-resourced, government-dominant context  in India.