It was astonishing two decades ago when word emerged that medical device industry giant Medtronic – famed for its pacemakers – had made $1-million grants for cardiologists at heart centers across the country to explore complementary therapies. One seeded the creation of a center at Scripps led by interventional cardiologist Mimi Guarneri, MD. Guarneri would go on to be awarded the Bravewell Award, become the founding president of the Academy of Integrative Health and Medicine (AIHM) and most recently be presenting her Live Better Now program for PBS. I checked in with her early this “heart month” of February to get a sense of the state of integrative cardiology.
My prep work for the Guarneri interview was admittedly thin – partly because I didn’t find much about the field. Unlike “integrative oncology,” web searches for “integrative cardiology” produced evidence of only a few centers or physicians who, like this cardiologist, are choosing to brand themselves as “integrative”. And also unlike “integrative oncology,” the subset of medical professionals who treat heart conditions with appreciation for the roles of integrative approaches has no parallel organization to the “Society for Integrative Oncology.” A search for an “integrative” special interest group at the American College of Cardiology came up empty.
Perhaps it is telling that, while Guarneri still self-identifies as an “integrative cardiologist,” after battling to build an integrative cardiology model at Scripps for 15 years, her present professional home is at her solidly interprofessional, community-based Pacific Pearl La Jolla center, rather than in a major hospital. Here is an edited version of the interview.
Weeks: It’s heart month at AIHM and elsewhere. I figure it’s been what, 20 years since your Medtronic grant? What has been going on with the field?
Guarneri: I haven’t done a mapping to know who has programs and who doesn’t. The program we were able to start with $900,000 from Medtronic, the Scripps Center for Integrative Medicine, seems to be one of the few that promotes itself as “integrative cardiology.” There are Dean Ornish’s programs – his are true integrative cardiology with diet, exercise, meditation, and the group format. I’m not sure how many hospitals have it. I know even with his research it took him almost two decades to get reimbursement for it through Medicare.
Weeks: Has the program taken off since Ornish got it reimbursed? I haven’t seen a lot of signs that it is being picked up everywhere.
Guarneri: It is a big commitment. Last I knew it was $250,000 to put in a hospital. Let’s get in touch with Dean.
We did. In an email response Ornish wrote:
“If it’s reimbursable, then it’s sustainable. Reimbursement is a significant driver of medical practice and medical education. As such, we are deeply grateful to CMS for creating a new benefit category to reimburse our lifestyle medicine program for reversing heart disease (currently 31 centers in 18 states, www.ornish.com) and to the many insurance companies who are also providing coverage nationwide. These sites are motivating patients to make bigger changes in lifestyle and achieve better clinical outcomes, larger cost savings, and greater adherence than have ever before been reported in an ambulatory population. This helps to create a new paradigm of health care.”
Weeks: This is great. And it doesn’t take many stents to pay for the $250,000 – for someone doing 700 per year like you were when you were at Scripps 20 years ago.
Guarneri: Yes it is good to see the expansion of the Ornish program – great work. But with some 4000 US hospitals and 23,000 cardiologists, that’s a fraction of the need. We need to see way more availability of integrative cardiology programs than that. The problem is misaligned incentives. We in the integrative field have always said that when we have the research things will change. But we have research in integrative cardiology. We have Ornish’s research. We have all the mindfulness research. It’s not only the clinical, but the cost savings from the Ornish programs. It’s the same as with climate change. We have the science but the economics don’t fit. We get paid for doing the stents and the procedures. The incentives to do the right thing are misaligned with the industry’s business model. We need to have payment incentives that are aligned with health creation.
Weeks: At least there are cardiac rehab programs with most hospitals everywhere that have heart programs.
Guarneri: They are good for what they do but they don’t go far enough. Cardiology lends itself so beautifully to integrative approaches. To get to root causes, you follow naturopathic principles. You look at sleep, diet, toxins, stress, anger, attitude, gratitude, inflammation, sleep apnea, diabetes. When you look at cardiovascular diseases you can go straight to root causes. The rehab programs don’t do that. There are at least now more discussion of lifestyle issues in cardiology meetings. But we’ve reached a point that we can’t only bring in lifestyle as secondary prevention.
Weeks: So how do we observe all this slow movement in cardiology and hold off dismay?
Guarneri: You can continue to be a voice for all that’s right or you can go off into the dark night. I look at many people around us who are raising the level of consciousness. We need to build that million strong movement we have talked about. So much of this is not a medical issue. It’s not a clinical issue. It’s a public health issue. It’s an issue like germs, like hygiene. I think in trying to promote and get support for our ideas that maybe we’ve been barking up the wrong tree. Maybe we should be promoting integrative health for cardiovascular problems as a public health issue.
Weeks: Well, if it took us 20 years to learn that – maybe we need to focus on figuring out how to build those public health relationships. Maybe a public option or Medicare for all will shift some incentives. Thanks for the time. Happy Heart Month!
Addendum Regarding Integrative Heart Health and the Public Health: Guarneri’s concluding direction brought to mind a powerful study by a team at Benson Henry Institute where some of the earliest integrative cardiology research in the 19980s-1990s was led by Eileen Stuart, PhD, ANP-BC. The team published an astonishing retrospective review in 2015 that concluded that, on average, the 4452 patients of their multi-modal relaxation program – for various conditions – showed a 44% diminution in use of conventional services (primary care visits, pharmacy, laboratory and hospitalization, combined) compared to matched controls who didn’t have the program. Imagine the media outpouring if a drug or high tech procedure had such an impact! At the end of the powerful article, the authors added this note:
“The data suggests that the intervention should be applied to all at risk populations, since the intervention has minimal risk, minimal cost and yields substantial benefits for patients with a wide variety of illnesses. The long-term effect of these interventions on healthy populations is unclear, but the data suggests that mind body interventions should perhaps be instituted as a form of preventative care similar to vaccinations or driver education. Such interventions are likely to be useful in population management and supported self-care, have negligible risk and cost and may help reduce the demand curve in healthcare. While the risk benefit ratio of this intervention is very favorable to further elucidate the effect size a prospective evaluation is called for.”