Vermont’s Primary Care Infrastructure

Contribution from Naturopathic Physicians

Testimony: House Health Care

Thursday, February 8th, 2007

Lorilee Schoenbeck N.D.

President, Vermont Association of Naturopathic Physicians

Independent physician practicing alongside conventional providers at Vermont Women’s Choice GYN Associates in Burlington, which is owned and operated by PPNNE. I am one of 8 primary care providers in our building, and the only general practitioner. I often get referred patients who have a non-gynecologically-related problem, in addition to patients who are seeking a more natural approach to gynecological problems such as infertility, uterine fibroids, vaginal infections and menopausal complaints. I am also the principle author, along with two conventional colleagues of a book entitled: Menopause, Bridging the Gap Between Natural and Conventional Medicine.

I am handing out a booklet which has been written for you: “Naturopathic Medicine in the 21st Century has been written to help educate healthcare policymakers….”

This committee is charged with the daunting task of offering solutions to big problems: uncontrolled costs, the epidemic of chronic disease, and related to that, the impending collapse in the primary care infrastructure.

The naturopathic profession has been actively considering these same issues for many years, and working with state and federal officials to integrate these solutions into mainstream health care delivery. I will pull some of my testimony from this booklet, but I urge you all to take this booklet home and read it carefully—for it offers a perspective that you might not otherwise hear from stakeholders in the current health care system.

Summary of Naturopathic Medicine

  1. Naturopathic physicians (hand-out curriculum—4,353 hours training)
  2. Trained in 4-5 year federal DOE accredited medical schools
  3. Bachelors degree with standard pre-med prerequisites
  4. “Naturopathic medical college prepares NDs with a biological education of the same breadth and depth that prepares an MD to be a primary care physician.”—Oregon Office of Educational Policy and Planning, 1998
  5. Half of what we do is offer conventional services.
II.N.D. Scope of practice
  • Licensed by VT Statute Title 26, Ch 81 “to prevent, diagnose and treat human health conditions and injuries.”
  • Qualified and licensed to “use diagnostic procedures commonly used by physicians in general practice, including physical and orificial examinations, electrocardiograms, diagnostic imaging techniques, phlebotomy, clinical laboratory tests and examinations and physiological function tests.” (Title 26, Ch 81)
  • Trained and licensed to prescribe both natural and conventional medications. treatments: nutrition, lifestyle counseling, botanical medicine, homeopathy, physical medicine, pharmaceuticals. Formulary under expansion via the VDH to include prescriptions necessary for primary care. Eligible for federal DEA #s.
  • A primary-care modeled practice. Not a treatment-driven practice.
III.Tenets of Naturopathic Medicine
  • First, do no harm
  • Vis medicatrix naturae (the healing power of nature)
  • Identify and treat the cause
  • Treat the whole person
  • Doctor as teacher
  • Prevention

g. Wellness

IV . N.D.s in primary care

  • Defining primary care:

"Primary care" means health services provided by health care professionals specifically trained for and skilled in first-contact and continuing care for individuals with signs, symptoms, or health concerns, not limited by problem origin, organ system, or diagnosis, and shall include prenatal care and the treatment of mental illness.” VT State Legislature, Health Care Affordability Acts 2006

  • Important components of primary care practice: (from the Am. Acad. of Family Phys.)
  • point of entry into health system
  • diagnosis and treatment majority of acute and chronic illness
  • coordination of referrals to specialized care as needed
  • health promotion, disease prevention, health maintenance, counseling, patient education

 Naturopathic physicians are primary care physicians

- ND’s are licensed under Vermont Statute Title 26 Chapter 81 as physicians who are trained and qualified “to prevent, diagnose and treat human health conditions and injuries".They treat most conditions that would be seen at any family practice office: school physicals, well-child exams, routine check-ups, cholesterol and BP screening, monitoring thyroid medication, treating illnesses A-Z.

  • ND’s use standard methods, such as medical history, x-rays, blood work, Pap smears and mammograms to treat or prevent illness.
  • ND’s use nutrition, lifestyle counseling, physical medicine, and both natural and prescription medications to treat or prevent illness.
  • ND’s are trained in primary care and are experts in preventive medicine.
  • ND’s are the only licensed physicians who have advanced training in nutrition and lifestyle counseling.

- "Naturopathic medical college prepares NDs with a biological and biomedical education of the same breadth and depth that prepares an MD to be primary care physician."

-Oregon Office of Educational Policy and Planning 1998

  1. Oversight—Public safety first:
  2. The primary concern of the naturopathic profession is the health and well-being of the public. That’s why we are doctors. And that’s why as doctors, we predominately use the gentlest and least toxic medicines available. These are often natural medicines, such as diet, nutrients or herbal supplements.
  • Use of natural medicines by the general public is high.
  • Studies consistently show that about 50% of the US population uses CAM. This is a number which has, and will continue to increase with time. In 1998, a UVM study (Dr. Magdelena Naylor) found that 54% of Vermonters used CAM. Most do not have access to health care providers knowledgeable in the use of CAM. As a result, most people who use supplements, herbal medicine, diet therapy etc. are self-medicating. We need more public oversight here. Any system of primary health care needs individuals trained to deal with the 50% of patients who are already choosing treatments outside the purvue of their conventional providers.
Oversight—Public safety
1. CAM use by the U.S. public

a. 50% of Americons use CAM on average

b. 54 % of Vermonters use CAM (1998 FAHC)

  • Most on supplements are self-medicating. (interactions/contraindications)
  • Conventional PCPs are not trained in CAM/supplement interactions etc.

Continuing to ignore the public’s use of CAM is a public safety issue.

Conventional providers are not trained in CAM. Their approach has been generally to warn patients and discourage its use. That approach has not succeeded in decreasing public use of natural medicines, nor do we feel it is an appropriate approach to dealing with CAM. Our solution is to integrate well-trained, licensed CAM providers, such as naturopathic physicians, into conventional PCP settings or at least promote communication between fields.

2. Oversight in training, testing and practice of naturopathic medicine

-The naturopathic profession has also been actively involved in enforcing standards of training, education, testing, professional regulation and government oversight in order to insure public safety.

  • 1. Created an accredited, standardized doctoral level training program for the Doctor of Naturopathic Medicine (N.D.) degree (recognized by the US DOE)
  • 2. Enforced rigorous national board examinations, administered by the North American Board of Naturopathic Examiners. Passage of both Basic Medical Science and Clinical Science Board Examinations are required for licensure.
  • 3. Supporting state licensing (VT Statute Chapter 25, Title 81.)
  • 4. Participates in professional regulation (VT Sec. Of State Office of Professional Regulation enforces Rules, Conduct, Licensing and processes complaints.)
  • 5. Participates in malpractice insurance
  • 6. Scientific research: Actively engages with the National Institutes of Health NCCAM and other institutions in researching the safety and efficacy of natural medicines.

The naturopathic profession continues to strive to advance standards of education, practice and regulation of the profession. All of our successes in these areas to date have been accomplished despite the persistant opposition of the prevailing medical establishment, which you see here well represented, and well-funded. As legislators, you have a unique opportunity to see the larger picture—and, a picture which is outside of the box of any individual stakeholder’s vision. At this time, I would like to offer a naturopathic perspective in answer to the questions I was emailed by Loring for this testimony:

What do we need to support and strengthen our primary care infrastructure: both in the long and short term?

Long term: I invite you to put aside what you currently know about how primary care is practiced, and just for a moment, envision with me a different scenario. Imagine a system in which parents and children are educated in the areas of nutrition, wellness, healthy lifestyles and self-care. Obviously this encompasses areas beyond our scope today, such as the educational system. However, the primary care setting must be one which supports and in fact, champions wellness education. Imagine that the primary health care provider of the future actually has meaningful training in nutrition. (This is not currently the case.) This provider also has received training in how to counsel patients in making healthy lifestyle and dietary choices. (This goes way beyond telling a patient to “eat better” or “exercise”. Counseling involves employing successful strategies to succeed at these goals.) The reimbursement system rewards, instead of punishes, doctors who spend time educating patients. There are procedure codes for various forms of wellness counseling, and providers aren’t only reimbursed for treating disease. When a problem is diagnosed, the least costly and invasive effective treatment is offered first. If a natural remedy is effective for the situation, it is offered. Prescription drug costs go down. More costly or invasive procedures are applied when needed, as are specialty referrals. This includes major acute illnesses, life-threatening disease and advanced chronic illness. If a problem is recurrent, the provider works with the patient to assess the underlying cause of the condition, and eradicate it when possible. Referrals to specialists are reduced, thereby decreasing the need for specialists, and ultimately, shifting the interest back toward primary care for physicians in training.

If you think about it—this looks a lot like the 7 major tenets of naturopathic medicine.

This is not only possible, it is actually happening. This committee took testimony last session from Washington State, which has integrated naturopathic physicians into their overall health care system. One physician who testified was Dr. Laura Patton, the Medical Director of Alternative services at Group Health Cooperative, one of the largest Managed Care organizations in the state. She testified regarding a survey Group Health took among their enrollees who used naturopathic physicians:

“With respect to naturopathy-I’m looking at a survey from a couple of years ago—59% of them reported decreased visits to primary care physicians, and about 48% reported decreased visits to specialists. And then another major driver of health care costs, over 50% reported decreased use of prescription medications.”

Short Term support to primary care infrastructure:

Increase access to licensed naturopathic physicians by passing H. 82.

  • H.82 / S.23 allows naturopathic physicians providing treatment within their scope of practice to be reimbursed for providing medically necessary health care services.
  • H.82 / S.23 applies only to services already covered by a health insurance plan.
  • Non-covered items, such as vitamins and herbal supplements are not included in H.82.

This bill will remove barriers so that more Vermonters can see naturopathic physicians. This will help relieve the burden on current conventional PCPs. The current system excludes any service provided or ordered by a naturopathic physician (including bloodwork, mammograms, Pap smears and other routine screening services.) We can no longer afford to marginalize a profession which is attempting to bring low-cost, natural treatments and preventions to the general public…especially when they excel at prevention and management of chronic illness.

Allowing access to the approach of naturopathic physicians is also the only way to generate data with which costs and efficacy can be compared side-by-side with conventional medicine. In other words, the only way to know if these naturopathic players are any good, is to allow them onto the field.

Provider Capacity

  1. 27 Naturopathic practices in Vermont, 25 open to new patients.
  2. Estimation: 10,000 total active patients at any given time.
  3. Probably 50,000 patients active within the last 5 years
  4. 1 ND per 22,000 Vermonters
  5. NDs probably at 50% capacity at this time.
  1. Regional distribution: fairly equitable (see map)

Most Vermonters have access to an ND within 20 miles.

A few outlying areas (i.e. Jay Peak), 40 miles

  1. By comparison:
  2. Connecticut

Anthem Blue Cross and Blue Shield of Connecticut:

-Provider type every 15 miles

-91 NDs. Total subscribers (?)

- Connecticut plans open for ND enrollment, (some demand)

Connecticut totals

-137 NDs practicing in CT. 3.5 million population.

-1 N.D. per 25,000 people (extrapolation from WA %: 1 ND per 2-4,000 subscribers)

  1. Washington

Regence Blue Shield

-Provider type every 5 miles in urban areas, every 25 miles in rural areas. Capacity is determined by demand, and assessed periodically.

-287 NDs serve 1 million subscribers. (1 per 3,400 subscribers)

-Provider numbers “about right” for subscriber population.

Washington state totals

-650 NDs in state of 6 million (1 per 9,000 capita)

  1. Alaska: no PCPs, no HMOs. It’s a fee-for-service state, with Pops, and they have a lot of access issues and shortages for every type of provider.
  2. 15 NDs in a state of 680,000. (1 per 45,000)

Summary of capacity: If included in coverage, the current 25 open ND practices today in VT could likely accommodate the majority, but not all of the demand. Projected recruitment to 50 NDs in Vermont by 2011 is feasible, which would provide 1 ND per 12,000 Vermonters. This is a comfortable number, and in line with other covered states. There would likely be some demand still for NDs at this ratio.