IM4US: Challenging Economic Disparities in Integrative Medicine

Integrative medicine offers immeasurable value in treating a multitude of health conditions. But the steep price of holistic services, and the fact that most are not covered by federal payors or private insurance, makes them inaccessible to many people, especially in poor and medically underserved communities.

One health justice organization is working to change all of that. 

Integrative Medicine for the Underserved (IM4US) promotes access to holistic medical services for all individuals, regardless of income or setting. 

IM4US is a consortium of diverse health care professionals passionate about sharing integrative medicine with a broad range of patients. The group formed at the 2009 Society IM4US logoof Teachers of Family Medicine (STFM) Spring Conference, where a handful of holistic doctors, primarily in family practice settings, met for the first time. Many were offering care in community clinics, where they witnessed the benefits of integrative care for medically underserved people, as well as the obstacles they face in accessing these services.

IM4US founder Richard McKinney, MD, along with other practitioners at the STFM conference, recognized a fundamental discrepancy between the core values of integrative medicine, which can benefit people from all walks of life, and the expensive out-of-pocket "boutique" settings which are the norm for delivery of holistic medical services.

McKinney, who was director of the Integrative Health Office at San Francisco General Hospital, soon attracted a core of practitioners who shared his belief that integrative medicine should be accessible to all people, not just the wealthy.

Socioeconomic status carries with it many stigmas, prejudices, and expectations. Concierge, cash-only models of integrative medicine influence both patients' and practitioners' beliefs and expectations around the type of person who can -- or even should -- receive this type of care. Patients who pay cash for a specialty medical service may expect to receive care in spa-like environments that are not accessible to nor welcoming of low-income people.

IM4US strives to paint a broader and more inclusive picture of the type of patients who receive integrative care, and the settings in which integrative services are offered. 

At first, the newly formed group of "health equity advocates" remained loosely connected through periodic conference calls. Today, nearly a decade later, IM4US is a well organized network of practitioners, medical faculty, and administrators with diverse expertise who share a common set of values articulated on the organization's website:

  • We believe health care is a rightMcKinney
  • We believe optimal health care focuses on wellness as much as on treating disease
  • We believe optimal healthcare addresses mind, body, and spirit
  • We believe that the social determinants of health must be addressed
  • We believe in the power of integrating diverse health care modalities and disciplines
  • We believe underserved patients and those providing their care need unique kinds of support
  • We belive collaboration and sharing improves patient outcomes and inspires providers to remain whole-heartedly engaged in this work

The organization is very deliberately inter-disciplinary, and represents MDs, naturopaths, nurses, acupuncturists, nutritionists, herbalists, homeopaths, and others.

Strain and Pain for Patients

Several factors contribute to the often staggeringly high cost of integrative medicine.

"In its best form, integrative medicine involves educating and empowering patients -- which takes time," said Connie Basch, MD, one of IM4US's founding members. "It's not your typical five-minute office visit -- it means using techniques like motivational interviewing, providing patient education, and offering additional modalities that aren't covered by traditional insurance."

In most settings, conventional insurance does not cover non-conventional modalities. Specialized diagnostic tests of the sort ordered by functional medicine practitioners, are rarely reimbursed, and carry hefty out-of-pocket pricetags. That puts them totally out of reach for low-income people. Keep in mind that according to the Bureau of Labor Statistics, the average American worker earns just under $46,000 per year.

"The patients we see are not simple patients -- it's people with complex, chronic issues who seek out integrative medicine," Basch continued. In rural communities like the small northern California town of Arcata where she practices, a large percentage of patients are covered through the Affordable Care Act, and they have very high deductibles.

"They pay lots of money for a plan that covers little, and then have to pay out of pocket for any extra services," she explained. "That adds strain and pain for patients." 

Ironically, Basch pointed out, while the vast majority of patients stand to benefit from things like nutritional counseling, insurance plans generally do not cover the services until a patient receives a qualifying medical diagnosis. In other words, they have to wait to be sick to gain access to modalities that very well could have prevented them from getting ill.

"Medical costs are bankrupting our society," she argued, adding, "this isn't just about the underserved -- it's about all of us. We need to be creative."

Functional and integrative medicine can be economically challenging even in affluent communities. According to surveys conducted by the Institute for Functional Medicine, clinicians who step outside of insurance-based practice models and into full-time, direct-pay, functional medicine often see income drops of up to 30%--at least in the first few years.

It can be very challenging to make the numbers work in an integrative practice no matter where it is located. In a low-income rural community or an inner-city community clinic, the issues are compounded and the solutions more limited.

For example, many integrative practices dispense nutritional supplements and herbal products as a way of creating revenue streams to offset the costs of long visits and in-depth personalized care. In less affluent communities, that won't fly. Few patients will have the resources to pay out of pocket for these products. Further, the appearance of impropriety around "profiteering" off patients is unacceptable to some practitioners working in poor communities.

IM4US leaders address this issue by educating members to purchase supplements at wholesale prices, which they can then sell to patients at lower costs. Alternatively, they teach the importance of eating whole foods, supporting efforts like community gardens, and educating patients about cooking with low-cost culinary herbs--turmeric, ginger, oregano--commonly found in expensive herbal supplements.

Power in Numbers

Group visits are one example of the kind of clinical creativity that IM4US promotes. The organization's  president, Priscilla Abercrombie, RN, NP, PhD, says she has found the group visit model extremely effective in the context of pain management. Chronic pain problems are very common in poor communities, and often lead to devastating consequences in the form of addiction to prescription and "street" opioids. 

Abercrombie, a board certified advanced holistic nurse, completed the University of Arizona's two-year fellowship in integrative medicine, and provided care at San Francisco General Hospital's Women's Health Center for nearly 30 years. At that time, "there was no official program at SF General for integrative medicine yet -- but I practiced it," she recalled.

She learned numerous integrative non-pharmaceutical pain management strategies easily conveyable to patients in a group setting. From anti-inflammatory diets incorporating foods like turmeric and ginger, to physical techniques like myofascial release, and self-care methods like meditation as ways to reframe pain, she identified and taught non-traditional alternatives to the more aggressive drug-based pain treatment strategies.

AbercrombiePriscilla Abercrombie, RN, President, IM4USGroup visits create an ideal context for teaching these modalities to patients who would not otherwise be able to afford to see functional medicine practitioners, Abercrombie told Holistic Primary Care.

Integrative medicine and holistic concepts are more readily welcomed in some communities than others. Rural locations present particular challenges. Holistically-minded practitioners sometimes encounter hostility from conventionally-minded colleagues as well as skepticism and mistrust from many people in their communities. Rural practitioners are often disconnected from one another owing to geography and distance.

This only adds to the sense of isolation and the financial burdens felt by many physicians practicing outside of larger metropolitan medical havens--even those practicing conventional medicine.

By building a network of like-minded integrative professionals from varied communities across the country, IM4US aims to reduce the sense of loneliness that some integrative practitioners experience. The organization's members create and share tools like patient handouts and educational materials. They exchange clinical pearls, and provide social and moral support for each other.

Preventing "Compassion Fatigue"

In some communities, IM4US practitioners are seeing signs that integrative care will eventually be welcomed in more mainstream environments.

Kaiser Permanente, the California-based integrated managed care consortium, offers some insurance-covered integrative services, including acupuncture, mindfulness, and chiropractic. Similarly, at the University of California, San Francisco's Osher Center for Integrative Medicine, physicians provide covered acupuncture, biofeedback, massage, and Traditional Chinese Medicine services to patients. 

Establishing holistic programs like these, particularly in areas dominated by conventional medicine, requires advocacy both on a grassroots level and also through policy change.

IM4US is involved in advocacy for integrative medicine at the federal, state, and local levels, and the group encourages its members to get involved. The organization offers annual memberships on an income-based sliding scale from as little as $5 yearly and up. Membership provides practitioners access to the various resources on the IM4US website, including a toolkit designed for teachers and practitioners of integrative medicine working in underserved settings, as well as early registration for the annual IM4US conference. 

The organization’s 8th annual conference, held June 21-23 at George Washington University, focused on the theme of  “Justice and Equity in Policy and Practice." The conference is another way for integrative medicine supporters to meet and network with one another.

"Most practitioners who attend the conference report feeling like they finally found their tribe," Abercrombie observed. For those who work largely with underserved patients, the event not only renews attendees' commitment to the meaningful work they do, but also reminds them that they are not alone in their efforts.

Networking and building relationships with other integrative professionals offers a kind of antidote to the compassion fatigue experienced by many clinicians working in poor communities. Practitioner burnout is a very real and very serious problem throughout the medical world, and especially so in communities where medical services are sparse, pay is low, and the medical problems are big and often compounded by social and economic distress.

IM4US Board member Renita Herrmann, MS, Certified Classical Homeopath, notes, "in my field of homeopathy, we can share very effective tools very cheaply." She values the fact that IM4US embraces healers across many modalities, and encourages them to bring their valuable skills to the table. "If you have information, share it,"

Integrative Med & the Opioid Crisis

Reflecting IM4US's current central policy focus on the opioid crisis, one of the activities planned at this year's conference is the organization of a Congressional briefing on non-opioid approaches to pain management.

"We know that a ton of integrative therapies are effective for the treatment of chronic pain," Abercrombie explained. The briefing will highlight research on non-drug pain management strategies like acupuncture, chiropractic, group medical visits, and mindfulness-based stress reduction.

"As integrative providers, we can offer so much that will help to solve these huge problems," founder Basch reiterated. Yet these alternative therapies rarely make their way into mainstream medicine.

Sharad Kohli, MD, IM4US Board Secretary and chair of the organization's Policy Committee, intends that his group's message to Congress will raise awareness around the need to deliver non-opioid treatment options to more patients through more sustainable channels. He and his committee advocate for the inclusion of multidisciplinary health professionals in federally qualified health center settings, and also for increased insurance coverage of holistic pain management therapies.

"There is good evidence that we shouldn't use opioids," Kohli said, "but with other non-pharmaceutical approaches like acupuncture, reimbursement is often very low or non-existent. Most doctors don’t have many other tools for treating pain, so they just prescribe opioids."

Kohli recommends that health professionals seeking to give voice to their underserved patients establish connections with organizations that teach basic advocacy skills, like Physicians for Social Responsibility, Doctors for America, or IM4US.

This year's IM4US meeting offers a pre-conference training session teaching participants how to conduct local grassroots advocacy work in their own communities, including developing talking points and communicating with legislators. "Clinicians need to understand the weight that they have in influencing health policy," Kohli suggested.  

To busy practitioners overstretching themselves just focusing on day to day patient interactions, health policy activism may sound like yet another thankless and unpaid task. But Kohli argues that physicians' expertise in the field uniquely positions them to influence lawmakers and health laws.

"We have weight amongst legislatures," he said. "It’s one thing for a CEO to talk about numbers, but personal stories from people on the front lines are very valuable. When we tell our patients' stories and show how these issues affect public health and patient lives, people listen to us."

Advocacy for the Underserved

When asked how other practitioners can support the IM4US mission in their own communities, Abercrombie proposed that on a personal level, "it's all about advocacy for the underserved." In a clinic setting, she said, it’s important to identify patients likely to benefit from integrative therapies and figure out how to either offer them the care they need, or connect them to others who can.

"We have skills like acupuncture -- but we also have a broader vision of what it means to have a relationship with a patient," she said. That broader view encompasses a range of ways in which to measure health and wellness, from physical activity and diet to what gives patients a sense of joy in their lives.

Echoing similar sentiments, Kohli said, "many view us as an integrative health organization -- but I view us as a social justice organization, striving for health equity. I believe integrative medicine is a tool that will help us get to that point. We focus on all of the factors, including the social determinants, that influence health -- and we also focus on self-efficacy, teaching people what they need to know to be healthy."

"Whether or not you call it 'integrative care' or have an official program doesn't really matter -- it's your approach to patients that makes the difference," Abercrombie added.

"We partner with patients in a culturally sensitive way. We expose patients to the best health and wellness information we have and teach them how to put it into practice. Many practitioners trained in integrative approaches are doing this work daily. Other people may not see it, but as individuals, we’re making a huge impact."

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