Achieving
BETTER OUTCOMES at LOWER COST
with NATUROPATHIC MEDICINE
Jill Sanders, ND
Dean of Clinical Operations
NCNM acknowledges the OANP for its contributions to this presentation.
Why are we here?
 ND’s offer cost-effective ways of preventing
and managing chronic disease
 MCO’s credential only a handful of NDs.
 Oregon has a pool of trained PCP’s that are
dramatically underutilized - in large part
because of insurance policies that are out-ofstep with market demands and needs.
Community Demand
 Every public meeting conducted by OHA for comments
on CCO transformation included demand to include
naturopathic care.
 Every public meeting conducted by OHA in 2010 for
comments on health insurance exchange included
demand to include naturopathic care.1
1. “Oregon Health Authority and Oregon Health Policy Board September 2010 Community Meetings,” Submitted by Oregon Consensus,
Portland State University, 10/4/10.
Licensed Naturopathic Doctors
 NDs are primary care providers (PCPs) who:
 Specialize in the prevention of illness, as well as the management of
chronic disease
 Trained in both natural and conventional evidence-based medicine and
experts in drug-drug, drug-herb, and drug-nutrient interactions
 Use conventional diagnostics and standards to diagnose and treat
illnesses and health conditions
 Treatments include: a variety of natural therapies including diet and
nutrient therapies, counseling, botanical medicine, lifestyle changes, patient
accountability, and conventional therapies such as pharmaceutical
medications.
ND Education
 Four-year accredited, graduate-level naturopathic
medical school
 U.S. Department of Education and the Carnegie Institute classify the ND
degree as a First-Professional Degree under Doctorate-Professional
(Clinical), on par with MD and DO
 Council of Naturopathic Medical Education (CNME) is a programmatic
accrediting agency recognized by the U.S. Department of Education
 Required to pass National Licensing Exam
 Naturopathic Physicians Licensing Examination (NPLEX)
 Basic Sciences and Clinical Boards
 Qualify for federal Stafford Loans: ND students graduating with
$150,000 - $250,000 educational debt.
ND Education
Residencies
• Residencies are currently available for 1, 2, or 3 years
• All are privately funded
• Residency sites range from private clinics, to community
FQHC clinics, to in-patient hospitals (Cancer Treatment
Centers of America)
• Expanding but not available for every graduate
• Majority are for primary care
In Oregon, Licensed NDs can:
• Diagnose, prevent, and treat disease
• Perform physical exams including orificial exams (oral, vaginal,
anal)
• Order x-rays, electrocardiograms, ultrasound, CT, MRIs, and
laboratory tests
• Draw blood and perform CLIA-waived lab tests in-office
• Perform minor surgery
• Deliver babies (with additional certification)
• Provide injections including vaccinations and IV medications
• Prescribe all natural & pharmaceutical medications needed in a
primary care setting
• Are eligible for Drug Enforcement Agency (DEA) numbers for
Schedules II-V (authority to prescribe controlled medications)
Standards of Care
• Taught conventional standards of care at NCNM
• Held to conventional standards of care in court of law
• Recognize all same standards of care when it comes to testing,
diagnostics and metrics
Primary Difference:
• Treatment selected based on whole-patient functional approach
vs. symptomatic approach
• Getting from Point A to Point B might look a little different, but
outcomes often better, cheaper to obtain and with greater
patient satisfaction (side benefits vs. side effects)
Billing & Reimbursement
• Hold seat on AMA Current Procedural
Terminology Editorial Panel/Health Care
Professional Advisory Committee
• Use same CPT, ICD-9 Codes and HCFAs
• Credentialed as PCP by some insurance
plans & as “alternative” by others
NDs Serving Medicaid,
Uninsured or Underinsured
• Credentialed as PCPs by Oregon’s Department of Medical
Assistance Programs for Fee-for-Service population
• Some Managed Care Organizations credential NDs with very
narrow parameters (i.e., only if working in FQHC)
• NDs successfully integrated in (short list):
Donated Services
• NCNM provides 16,220 visits annually at FQHC community
health clinics (9,077 ND, 7,146 LAc) and is a member of the
Coalition of Community Healthcare Clinics.
The Most Underutilized
Primary Care Workforce
State-wide capacity
•720 active licensed in Oregon
•~641 (89%) estimated to practice primary care
•~500 (70%) are working at less than 80% capacity
•~547 (76%) of NDs surveyed indicated they would apply to get
credentialed with CCO to see OHP if they could
Tri-county capacity
•426 active licensed in tri-county area
•~379 (89%) estimated to practice primary care
•~285 (67%) are working at less than 80% capacity
•~311 (73%) of tri-county NDs surveyed said they would apply to
get credentialed with CCO to see OHP if they could
Capacity
Potential Capacity for ND's to take
on OHP Patients – State
50
40
30
NDs operating at <80%
capacity %
20
10
0
0%
0-20% 21-40% 41-60% 61-80%
100%
Potential Capacity for ND's to take
OHP Patients - Tri-county
40
35
30
25
20
15
10
5
0
ND's operating at < 80%
capacity
0%
0-20% 21-40% 41-60% 61-80% 100%
Addressing the PCP Shortage
Remove all barriers to insurance coverage and Oregon
could increase its PCP workforce by 15% immediately*.
Naturopathic physicians are the fastest-growing
segment of the full-scope primary care workforce.
ND medical schools graduate 500 NDs each year.
*adding 640 ND PCPs into the pool of 4,112 family medicine, general internal medicine, general practice, pediatrics, geriatrics
and adolescent medicine MD/DOs. Oregon Health Professions: Occupational and County Profiles, Office for Oregon Health Policy
& Research (Oregon Health Authority), April 2011, p. 64)
Oregon Has a Vested Interest in
Covering Naturopathic Physicians
 Cost-Effective
 A Solution to
Primary Care
Shortage
 Community
Demand
NDs Prevent Chronic Disease and
Decrease Health Costs
 NDs are the only PCP’s trained extensively in
counseling, nutrition, exercise, prescriptions, and
stress management to specifically address the
prevention and early intervention of chronic diseases
 In Washington, naturopathic care was projected to
result in up to 40% reduced cost for chronic and stressrelated illness, as well as 30% cut in specialist
utilization1, leading to Blue Shield’s voluntary decision
to credential NDs as PCP
1. Henry. 1995. King County Medical Blue Shield Phase 1 Final Report: Alternative Healthcare Project Steering Committee. August 5,
1995.
Outcomes & Metrics
 Central City Concern’s Old Town Clinic reports that the
NDs on their staff “perform just as well as, and in some
metrics out-perform, MD internists” in all metrics.
– Rachel Solotaroff, MD, Medical Director, Old Town Clinic
 A naturopathic clinic was a top scorer in all categories
of patient experience, an important metric in improving
health.1
1. Your Voice Matters: Patient Experience with Primary Care Providers in the Puget Sound Region, 2012 Community Checkup
Overview, conducted by Puget Sound Health Alliance. www.WACommunityCheckup.org
Cost-Savings
of Naturopathic Medicine
•Finding efficiencies for insurers
•Decreased use of pharmaceuticals
•Decreased use of
specialists
•Examples of cost reductions
Evidence of Cost-Savings
Washington
“With respect to naturopathy…59% of
[users] reported decreased visits to [MD]
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.”
– Laura Patton, MD, Medical Director of Alternative Services at Group
Health Cooperative, Washington State (in testimony before the Vermont
House Health Committee, March 3, 2005)
Evidence of Cost-Savings
Ontario1
In a 2011 survey of Ontarians who use naturopathic doctors:
28% report use of prescription medicine was significantly or
noticeably reduced
19% report reduced visits to the hospital
18% report reduced use of expensive medical specialists
The survey also found:
57% of Ontarians believe naturopathic medicine is leading to
better health outcomes for those who use it
1. Attitudes Toward Naturopathic Medicine. Innovative Research Group. September 1, 2011. www.innovativeresearch.ca,
http://www.ccnm.edu/ontarians_say
Evidence of Cost-Savings
Vermont1
 VADA (Vermont Auto Dealer’s Association)
wellness program administered by NDs:
 saved nearly $1.5 million in medical costs the
first year they made Naturopathic Medicine
available to its members.
 Saved $1,800 per employee.
 Produced a return on investment of $21 for
every $1 spent in direct & indirect costs.
 Only 0.2% increase in per member claims
costs (2005) compared to national average
of 7%.
 Each VADA-identified health risk showed
improvement over two years (chart).
Risk
Reduction
Hypertension
36%
Cardiovascular risks
35%
High cholesterol
16%
Physical inactivity
21%
Smoking
17%
Excessive stress
25%
1. Vermont Automobile Dealer’s Association and Green Mountain Wellness Solutions http://www.greenmountainwellness.com/ ;
http://www.vermontada.org/wellness.asp
Summary of Studies
 Improved outcomes in all of the 13 clinical studies
meeting systematic review criteria
 Benefits for conditions ranging from intractable pain
and disability to epidemic chronic diseases
 Significant employer, participant, and societal savings
in cost-effect analyses
True Primary Care
 67.7% of patients in WA State who receive
Naturopathic care do not receive concurrent care from
an MD/DO for their RFV (reason for visit);
Naturopathic care is not “add-on” medical care in
most cases.1
1. Cherkin DC, Deyo RA, Sherman KJ et al. Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists,
and naturopathic physicians. J Am Board Fam Pract. 2002;15:463-472.
Legal Requirements of Insurers
Affordable Care Act, Section 2706
(a) Providers- A group health plan and a health insurance issuer offering
group or individual health insurance coverage shall not discriminate with
respect to participation under the plan or coverage against any health
care provider who is acting within the scope of that provider's license
or certification under applicable State law. This section shall not
require that a group health plan or health insurance issuer contract with
any health care provider willing to abide by the terms and conditions for
participation established by the plan or issuer. Nothing in this section shall
be construed as preventing a group health plan, a health insurance issuer,
or the Secretary from establishing varying reimbursement rates based on
quality or performance measures.
(b) Individuals- The provisions of section 1558 of the Patient Protection
and Affordable Care Act (relating to non-discrimination) shall apply with
respect to a group health plan or health insurance issuer offering group or
individual health insurance coverage.
What Do Patients Need?
 Integration of naturopathic physicians into CCOs (& all
insurance) to meet the primary care needs of Oregon
 Removal of credentialing barriers currently imposed on NDs
 Coverage of the SAME services that are provided, regardless
of whether provided by naturopathic doctors, medical
doctors, osteopathic doctors, nurse practitioners and
physician’s assistants
Common Insurance Pitfalls to Avoid
Many private policies create barriers to care that drive
up costs, including policies that:
 Refuse to cover prescriptions or vaccinations from NDs.
 Refuse to cover labs or diagnostic images ordered by NDs.
 Place arbitrary annual caps – often $1,500 or less – on services
rendered by an ND. Sometimes labs and diagnostic images are
applied toward this cap.
 Provide “illusory benefit” to achieve market advantage – i.e.,
saying they’ll cover services for a migraine, but not a pap
smear.
 These policies force many to duplicate their office visit with
an MD, DO, or NP to get the same test, prescription or lab
ordered…and drives up healthcare costs
Questions?