It's no surprise that the demand for complementary and alternative therapies has been booming in the United States over the last few decades. And it will continue to grow, says David Eisenberg, M.D., of Harvard Medical School and author of the landmark 1993 survey of complementary and alternative medicine use by the American public.
Chronic pain now is treated routinely with adjunctive therapies such as acupuncture and massage therapy; herbal medicine is already a $100 billion global industry; integrative medical teams soon may become key players in medical homes and self-insured employer groups; and the growing obesity epidemic necessitates a multidisciplinary tactical approach that includes mindful eating, culinary education and coaching, among other skills, he says.
Simultaneously, over the last decade we have seen the steady increase in the number of hospitals that offer complementary and alternative medicine. With U.S. consumers spending almost $40 billion out of pocket for this care, hospitals clearly are motivated to look for ways to tap into this market while meeting their constituents' needs and differentiating themselves in the marketplace.
To understand this phenomenon better, Samueli Institute, in partnership with Health Forum, conducted the "2010 Complementary and Alternative Medicine Survey of Hospitals"to garner in-depth information about the CAM programs and services being offered in U.S. hospitals. The survey was divided into four major areas of inquiry:
- types of services and rationale
- finances and reimbursement
- planning and staffing
- evaluation and research
The 42-question "Complementary and Alternative Medicine Survey of Hospitals" was mailed to 5,838 hospitals in the United States in early 2010. A total of 714 responses were received, for a response rate of 12 percent. Of these, 42 percent of hospitals (up from 37 percent in 2007) stated that they offer CAM services.
"Hospitals are recognizing that many of their patients see CAM as an integral part of managing their health, illness and recovery," says Ian Morrison, Ph.D., an internationally known author, consultant and futurist specializing in long-term forecasting and planning. "Smart hospital leaders will figure out how to integrate these services to broaden their appeal to a growing segment of patients who truly value these services (and often are prepared to pay out of pocket to secure them). This report provides the evidence for how widespread this demand is and what hospitals are doing about it."
As reported in 2005 and 2007, the hospitals most likely to offer CAM services are urban hospitals (72 percent). A typical hospital offering CAM is in the Eastern or Midwestern United States and maintains between 50 and 300 beds. The following are some highlights of the findings and some commentary on the trends; percentages are based on the 299 respondents that offer CAM services.
Types of services and rationale: The most popular services or therapies offered on an outpatient basis are massage therapy (64 percent), acupuncture (42 percent) and guided imagery (32 percent). On an inpatient basis, the top therapies are pet therapy (51 percent), massage therapy (44 percent) and music/art therapy (37 percent).
"At Mayo Clinic, we saw a real 'snowball' with massage therapy in the hospital," says Brent Bauer, M.D., director of the complementary and integrative medicine program at the Rochester, Minn., clinic. "One small study in cardiovascular surgery patients showed a significant reduction in anxiety, pain and tension." When a second study confirmed this, the cardiovascular surgery division hired certified massage therapists to make massage therapy a routine part of the care following open-heart surgery. This soon was followed by similar efforts in other areas such as colorectal surgery and thoracic surgery. Now, he says, massage therapy is considered a routine part of the care for those surgical patients at Mayo who want it.
"I have also been impressed with the effects of simple interventions, such as making nature sounds available in the patient rooms, or receiving a visit from Dr. Jack, our lead therapy dog, and how readily these have become accepted as part of the care of our patients — right along with the top-notch, cutting-edge technological care that they receive," says Bauer.
Key reasons hospitals gave for offering CAM services were patient demand (85 percent), clinical effectiveness (70 percent) and reflecting organizational mission (58 percent). In choosing which therapies to offer, hospitals again are relying on patient demand (78 percent). Evidence basis (74 percent) and practitioner availability (58 percent) ranked next.
Eighty-two percent of hospitals reported they do not offer herbal supplements in the hospital pharmacy, and less than half (45 percent) stated they offered nutritional supplements. Sixty-seven percent report having policies in place regarding patients' use of herbal and nutritional supplements during their hospitalization, and 43 percent of anesthesia departments have policies regarding patients' use of herbal or nutritional supplements before or after elective surgery.
Carol Schoenecker, R.N., integrative therapies coordinator at University of Minnesota Medical Center in Fairview, says she is delighted to see that hospitals are responding to the rising consumer demand. In fact, there is so much demand for massage therapy at their three hospitals (totaling 849 beds) that they are unable to keep up.
Finances and reimbursement: Eighty-three percent of responding hospitals stated that their startup costs were below $200,000, indicating that these programs can be initiated with relatively little money. Forty-one percent characterized their programs as breaking even. Interestingly, of the hospitals with programs not breaking even, 68 percent stated that they never expected to break even, indicating that the programs likely were viewed as part of the organizational mission or as a loss leader. Patient self-pay (69 percent) continues to be the predominant mode of payment for CAM services; this, unfortunately, forms a barrier to access.
Planning and staffing: Strategic and business planning for CAM efforts generally are lacking in hospitals. Support for the CAM programs came from hospital administrators, who were mostly responsible for launching (39 percent) and continuing to champion (33 percent) the organization's CAM efforts. Such support bodes well for the sustainability of these programs.
However, only 39 percent of CAM programs had their own business plan, and less than half of hospitals reported that CAM was included in their hospital strategic plan. Seventy-eight percent of hospitals said they had good to mediocre levels of referrals from their medical staff, an indicator that physicians are accepting the role of CAM therapies in caring for patients.
Evaluation and research: Patient satisfaction (85 percent) seems to be the metric of choice in the evaluation of CAM services, followed by volume (57 percent). Outcomes research is definitely a weakness of hospital CAM efforts: Only 42 percent of hospitals are conducting any kind of outcomes assessments. The greatest challenges faced by hospitals in implementing programs are reported to be budgetary constraints (75 percent) and lack of evidence-based studies (43 percent).
With regard to the future, of those hospitals that are not currently offering any CAM services, 7 percent stated there were plans to do so. Of those respondents who had previously offered CAM programs but had discontinued them, the reasons they offered were poor financial performance (42 percent), general cuts in nonessential programs (29 percent), lack of medical staff support (29 percent) and lack of community interest (29 percent).
Whole Person Health
Clearly, hospitals are paying close attention to the needs and desires of their communities and patients when choosing to offer CAM services and, if so, choosing which therapies to offer. Many hospitals include community health and "whole person" health in their mission statements, making CAM services a natural fit.
"The rise of complementary and alternative medicine reflects the continued effort on the part of hospitals and caregivers to broaden the vital services they provide to patients and communities," says Nancy Foster, vice president for quality and patient safety at the American Hospital Association. "Hospitals have long known that what they do to treat and heal involves more than just medications and procedures. It is about using all of the art and science of medicine to restore the patient as fully as possible."
Sita Ananth, M.H.A., is the director of knowledge services at the Samueli Institute in Alexandria, Va., and is the author of this study. She is a regular contributor to H&HN Daily.