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Learn lessons from Tri-Rivers’ experience
In recent years, an increasing amount of press has been given to "alternative medicine." Everything from acupuncture to aromatherapy has been covered in publications as varied as Time magazine and The Physician Executive, both of which featured cover stories on it last fall.
Depending on which numbers you believe, anywhere from 10% to 40% of Americans use complementary medicine, whether it’s in the form of vitamin and herbal supplements or massage therapy. According to a recent study in the Journal of the American Medical Association, the number of visits to alternative practitioners in 1997 exceeded the number of visits to primary care physicians by 243 million.
Because becoming more "customer" focused is increasingly important for medical practices, it makes sense that some are moving toward melding their practices with certain alternative therapies. One practice that has taken the leap is Tri Rivers Surgical Associates, a seven-physician orthopedic practice in Pittsburgh. In September 1998, it opened the Institute for Alternative Medicine, also in Pittsburgh.
"In the last 18 months, interest in alternative care has increased markedly among our patients," says Martha C. Hamilton, CPA, Tri Rivers Surgical’s executive director. "This is what initially compelled our physicians to research alternative medicine aggressively and objectively, and to look at the perceived benefits of complementary care from our patients’ point of view."
Tri Rivers’ physicians said patients defined complete musculoskeletal care more broadly than traditional practitioners. For example, many patients turn to chiropractic and massage therapy for back pain. "Patients don’t hold biases," Hamilton explains. "They will try alternative care if they think it can help. In our practice, we’ve always tried to be at the forefront of change, so the growing interest in alternative care is something we needed to address."
First, Tri Rivers’ physicians concluded that they had an ethical responsibility to provide their patients with accurate information. "We needed to be informed, honest, and nonjudgmental," Hamilton says. "Then, as we learned more about alternative care, we saw that it could complement our approach to musculoskeletal care."
Hamilton and the physicians also recognized that this was a unique business opportunity. No other physician practice in the market had opened an alternative medicine center. Although there are many alternative medicine practitioners in Pittsburgh, most are independent; and few programs provide a truly integrative approach — one in which traditional and alternative practitioners work closely together as part of the same organization.
"We felt patients would be best served if we could bring orthopedic surgeons and alternative practitioners together in mutually inclusive way," she says. "We wanted to provide our patients with credible information about the efficacy of certain alternative therapies and give them a safe’ place to learn about and explore alternative care options."
Hamilton says another reason for diversifying into alternative medicine is changing reimbursement — specifically, a possible move toward "episode of care" payments. This compels providers to examine their own preparedness, she says.
Under this model, providers will receive global payment for a specific patient issue, like back pain, says Hamilton. "This means we would receive one payment for all the services the patient would need — whether it’s neuro-surgery, an MRI, bed rest, or chiropractic care. If we don’t have the ability to treat the patient with our staff or independent contractors, we’re not in a position to accept episode-of-care payments. If that payment mechanism is a potential next step in the market, why wouldn’t we start looking for ways to provide a broader range of care?"
Once Tri Rivers Surgical made the decision to embrace alternative care, Hamilton and the physicians identified the scope of service.
At first, they focused on musculoskeletal care — "It’s what we know best," she says — but quickly found that patients often have related concerns. These can encompass nutrition issues, such as supplements, and lifestyle issues, like exercise.
Tri Rivers hired a chiropractor to serve as medical director of the institute, as well as a certified massage therapist and a certified registered nurse practitioner, who provides nutrition and lifestyle counseling. Tri Rivers expects to add other practitioners — including an acupuncturist — as the institute grows.
"Rather than providing a full scope of alternative care right away, we focused on core services," she says. "For patients who want information on other therapies, we make referrals to practitioners whom we think are reasonable."
According to Hamilton, the choice of practitioners was a crucial decision.
In addition to having an excellent understanding of musculoskeletal management, the chiropractor chosen by Tri Rivers trained at a school with a conservative curriculum. He believes in an integrative approach and shares with the physicians the philosophy that care shouldn’t be over-utilized. The massage therapist trained at one of the nation’s top massage therapy schools, holds national certification and is considered an expert in neuromuscular massage. The nurse practitioner has 10 years of emergency department experience and — as a cancer survivor who used nutrition, exercise, and spirituality to assist in her recovery — brings a unique perspective.
"It was very important for us to find practitioners with whom we could work in a mutually respectful way," Hamilton says.
With the staff in place, Hamilton and the physicians began building the program. They gave the center a name, settled on a temporary location, hired support staff, and began to market the institute. Marketing consisted of developing a "corporate" image that was distinct from the Tri Rivers image, but also made a connection to Tri Rivers’ physicians to build credibility.
"Our patients tell us that they’re interested in alternative care, but that they want to know their doctors are involved," Hamilton says.
Tri Rivers announced the institute through letters to patients, referring physicians, and other groups, including the local chamber of commerce and health food stores. Dozens of these letters included gift certificates for services.
Tri Rivers sent news releases, distributed an original newsletter to more than 15,000 households, and used print and radio advertising to build awareness. It also arranged for the institute’s staff to participate in community events, such as health fairs and health education seminars at bookstores, hospitals, and arthritis support group meetings. Future marketing efforts will include targeting more directly and aggressively those people who are likely to use the institute’s ser vices — women 35 to 55, and senior citizens.
According to Hamilton, the institute has seen a steady increase in patient volume. The practitioners now work at about 30% capacity, but that number is rising. "We’re growing every day, but the growth has been slower than we projected. We had initially thought it would take six months for the institute to break even. It now appears it will take nine months."
Another challenge has been the search for a permanent site. Currently housed in the chiropractor’s prior office, Tri Rivers is looking for retail space that will provide excellent street visibility, as well as room for the institute to host community programs, like yoga classes and infant massage. "Without a permanent site, we held back on some marketing," she says.
Physician reaction to the institute has been surprising, she says. "We expected to hear from some referring physicians who would be skeptical, and we did. We’ve heard from many more who are supportive and think it’s an idea whose time has come. But what surprised me most has been our own doctors. There have been moments when they realize how far they’ve strayed from their comfort zone. They recognize, though, that this is a natural reaction to something different and new."
Another issue to deal with was reimbursement, which for many alternative services is non-existent. Hamilton sees this as both positive and negative. "Consumers spend billions of dollars on alternative care," she says. "The fact that services are out-of-pocket provides some insulation against declining reimbursement. Still, I think that more people would pursue alternative therapy if it were covered by insurers."
Despite these obstacles, Hamilton says the practice doesn’t second-guess its decision.
"This is the direction medicine is going," she says. "We look at the institute as a way to provide safe, reasonable alternative care and to meet market demand without losing sight of our quality-of-care objectives."
• Martha Hamilton, CPA, Executive Director, Tri Rivers Surgical, Pittsburgh. Telephone: (412) 367-0600.