Sunday, May 19, 2013

Integrative Medicine as Innovative Medicine: The Economics of Inpatient Integrative Medicine

Thought the following is timely as we struggle with healthcare costs and innovative models of delivery.

Perceptions of Medical Directors and Hospital Executives Regarding the Value of Inpatient Integrative Medicine Programs

Richard J. Gannotta, NP, MBA, James Zoller, PhD, Jeffrey Brantley, MD, 
Andrea White, PhD


Objective: The objective of this study is to identify and assess measures of success of inpatient integrative medicine programs by exploring and comparing the experiences of program medical directors and the hospital executive responsible for inpatient integrative medicine programs in the United States.
Design: An exploratory qualitative approach was selected for the study, surveying a purposeful sample of approximately ten healthcare institutions with inpatient integrative medicine services.
Participants:  From each of eight participating healthcare institutions, the integrative service/program clinical director (physician) and the non-clinical executive/ director, charged with general program administration and budgetary responsibilities for the program participated in the study.
Measures: A one-on-one or group (both the executive and clinician) semi-structured survey via telephone was conducted to identify critical factors associated with the success or failure of the program in three domains: 1) clinical outcomes, 2) financial performance, and 3) patient satisfaction.  The interviews were recorded and analyzed to identify key themes.
Results: In general, responses from medical directors and hospital executives regarding there perceptions of the value of the inpatient integrative program and the critical success factors associated with those programs were consistent and positive across the three domains investigated.  
Conclusions: Findings suggest that inpatient integrative programs are positively regarded by program leaders who believe that the service adds value as demonstrated in a number of key factors associated with clinical outcomes, patient satisfaction and financial performance.  Additional study to quantitatively assess program impact would be a logical next step.     

Increasing demand for integrative and complementary and alternative medicine (CAM) has led to its incorporation into a variety of patient settings. Some healthcare facilities have instituted inpatient programs specifically offering integrative medicine or CAM services. Despite this growth and due to a lack of consensus regarding a definition of a CAM inpatient service or program, the total number of inpatient programs in integrative medicine is difficult to determine.  This lack of a clear definition limits those institutions considering implementing such a program from easily recognizing model programs or their structures.
In addition, little scholarly work exists to assist in program development or analysis of factors associated with a successful inpatient programs. Furthermore, no studies in the literature assess the perspectives of program leadership on performance in centers where a service has been identified and implemented.
As organizations look at new strategies to define clinical value, market share and recruitment and retention efforts, many may consider adding integrative programs. Further, growing consumer awareness may drive healthcare organizations/hospitals to “reinvent” themselves by challenging traditional approaches to care delivery.  These factors may encourage organizations to consider the inclusion of inpatient integrative medicine programs (1). Because so little is known about the value of these programs in these increasingly competitive and challenging times, the perspectives of CAM program medical directors and the responsible healthcare executive experienced with these programs become particularly important.  These individuals can shed some light on CAM’s value to the bottom line, to patient satisfaction, and to quality care.

Research Question:
The objective of this study was to identify and assess measures of success for inpatient integrative medicine programs by exploring and comparing the experiences of program medical directors and the responsible hospital executive. The research question is what value do inpatient CAM programs offer their organizations from the perspectives of hospital executives and medical directors?
The goal was to examine perspectives of key people involved in existing integrative medicine programs in inpatient settings and determine their assessments of the success of inpatient integrative medicine programs. This determination was made by identifying and analyzing themes and findings related to program performance.  


The study was approved by the Medical University of South Carolina Institutional Review Board.
An exploratory qualitative approach was selected for the study surveying a purposeful sample of eight healthcare institutions with inpatient integrative medicine services selected from the AHA Health Forum (2) CAM survey participants, The Bravewell Collaborative (3) and an internet search. Of the programs surveyed seven were part of an integrated delivery system and one operated as a free standing community hospital.  The hospitals in the study offered at least one of the modalities which are part of the four major categories of complementary and alternative medicine recognized by the National Center for Complementary and Alternative Medicine (4). These modalities included, biologically based practices, energy medicine, manipulative and body-based practices, and mind-body medicine. In addition Traditional Chinese Medicine (e.g.; acupuncture) was also identified as a modality offered to inpatients. 
The participant programs average years in operation were 6.75. 
Selected program directors and executives were contacted by e-mail or by telephone to determine if they were willing to participate in the study. 
Four integrative service/program clinical directors (physician), five responsible executives, i.e.; the primarily non-clinical executive/ director, and one “hybrid” i.e. an individual who functioned in both roles, were identified and included in the study.
A semi-structured survey interview was conducted via telephone with each program participant to identify critical factors associated with success or failure of the program in three domains: 1) clinical outcomes, 2) financial performance, and 3) patient satisfaction (5).  The interviews were recorded and subsequently analyzed to identify key themes.

Data Collection

Data was acquired by focused interviews using a prepared interview guide for each participant.  This semi-structured interview guide allowed participants to be asked questions that allowed for open-ended responses.  In addition to audio recording, field notes were taken which allowed the researcher to write down impressions and ideas about other questions that might be useful to ask.  Interviews were conducted via telephone.  In most cases, questions were intentionally open ended and non directive, with participants encouraged to expand on their answers if they so desired.
The recorded interviews and the text of the interviews were analyzed for themes as well as direct (positive and negative) answers to the questions posed. Initial responses were followed by more penetrating questions from the interviewer.  The questioner avoided providing any information about other participants’ responses to prevent the introduction of bias.
Questions asked in the instrument were adapted from balanced scorecard indicators noted

in Ransom, Joshi, and Nash (6).

In an effort to enhance the relevant value of information for organizations considering

starting programs, several indicators were expanded by the author to increase the depth

of responses.

Questions Asked during interview

Clinical Outcomes 

·      In what ways has the integrative medicine service had an impact on clinical outcomes? (positive, negative, no change)

·      In what ways has the integrative medicine service had an impact on length of stay? (increased, decreased, no change)

Patient Satisfaction

·      In what ways has the integrative medicine service had an impact on patient satisfaction? (positive, negative, no impact), (why/why not?)

·      How does the integrative medicine service compare to other inpatient programs/services with respect to patient satisfaction? 
            (positive/better, negative/worse)

Financial Performance

·      Does the organization expect the service to be profitable? (yes/no), (why/why not?)

·      Is the service profitable?
·      Are there any plans to discontinue the service?
·      Are there plans to expand the service?
·      Are there plans to contract/shrink the service?

Questions were open ended with the interviewer (where applicable) following up

with additional inquiry e.g.; in what ways has it?   

Data Analysis

Responses collected from the interview process were initially coded into words and phrases by the investigator. These words and phrases were analyzed within the context of the question asked. Frequency data provided the number of statements/responses per category.
These responses were then coded into categories (focused coding), which combined smaller coding units and repeating responses into larger ones which identified critical factors associated with the success or failure of that element the program and any key themes.   

Clinical Outcomes 

Initial Coding            revealed a number of repeating words and phrases revolving around; “pain control”, “reduction in the use of pain medication”, “less medication usage”, a “reduction in nausea and vomiting” after treatment and or surgery, an enhanced sense of “well being”, “less stress and anxiety”, “length of stay reductions” associated with medication reduction and “positive” post operative outcomes.           
Focused Coding of these words and phrases demonstrated that there was belief that overall clinical outcomes were improved. This improvement was seen in the areas of:
1.     Pain reduction, and the need for less pain medication 
2.     Reduction in nausea and vomiting
3.     Reduction in stress and anxiety and greater sense of well being
4.     In general terms a belief that length of stay decreased
Patient Satisfaction

Words and phrases associated with responses for these questions included; overall “positive scores”, positive “letters” specifically referencing the integrative service, “increased satisfaction scores” associated with specific specialties within the departments of surgery or medicine, positive “impact on work culture” within the organization and a desire to choose the hospital because of the service.
The key themes associated with these responses include:
1.     A belief that patient satisfaction associated with the service is positive.
2.     The inpatient integrative service positively influences satisfaction scores for other departments i.e.; medicine and surgery.
3.     In general there is the perception that work culture is positively influenced by the program
4.     Satisfaction with the service may influence patient choice.

Financial Performance

Initial coding produced a large number of responses to this multi-part question specific to profitability and the programs future (discontinuance, contraction or expansion). The largest number of responses were associated with profitability and included; inpatient integrative service seen as a “loss leader”, part of the organizations “mission”, key for “attracting patients, physicians and clinical/support staff”,  part of overall “strategy” and offering a “competitive advantage” in key markets.
Additional responses noted that program profitability could be demonstrated by its impact on “reduced medication use”, “shorter lengths of stay”, “incremental business” and that the success of key service lines is increasingly influenced (positively) by the inclusion of integrative medicine.
Funding sources included leveraging “outpatient program funds”, allocations from “other divisions”, “grants / research funding” and “philanthropy”. All study participants indicated that there were “no plans” to discontinue or scale back there program. The majority surveyed planned on “adding modalities and services” not currently offered.
Focused coding revealed the following key themes:
1.     Expectation that programs cover expenses
2.     Funding was derived from four primary sources
a.     Leveraged (integrative medicine) outpatient margins to cover inpatient programs
b.     “Other” hospital divisions/services
c.     Philanthropy
d.     Grants /research
3.     General perception that better clinical outcomes associated with inpatient integrative medicine programs have a positive impact on financial performance
4.     The program is a key part of strategy or mission and a competitive advantage for the organization.
5.     Enhances the organizations financial performance by
Attracting patients
Recruiting and retaining hospital staff
The questions posed in this study are important to hospital administrators and clinicians because integrative medicine/CAM programs are a relatively new addition as a hospital service offering, and information regarding their performance is limited. From an economic and budgetary perspective, those programs which are able to demonstrate added value to the organization will, in general, be more successful in securing the resources necessary to maintain/expand their operations. Finally, few resources exist for those healthcare organizations considering adding an inpatient integrative medicine program.
The present study looked at the perceptions of program leaders, both clinical and administrative on what value and which success factors were associated with there programs success, failure and future direction. The study sample was homogeneous and there were no significant differences in responses between either clinical leaders or executives. Furthermore a relatively consistent list of critical factors associated with program success or failure was identified. This list can direct future scholarly work into areas where perceived value is high and linked to program success.
In addition, the study identified additional benefits associated with inpatient integrative medicine programs including an enhanced work culture, as an effective strategy for employee recruitment and retention , in creating an overall sense of less stress and anxiety for staff directly or indirectly connected with the program and as a positive differentiator from other providers  in there local community,     

The primary limitation to the study was identifying programs which met the criteria for an operating inpatient service. Initial criteria included programs operating for more than three years, a structure which had an identified clinical and administrative leader, and a mechanism whereby an inpatient had access to the service via standing orders, consultation or nurse driven protocol.  Of the eight hospitals surveyed five programs operated for greater than three years and three programs from one to three years. Because each of the programs not meeting the criteria for length of service also operated an outpatient service which had been in operation for greater than three years, the initial inclusion criteria was modified to allow these programs in the survey.
Although the parameters for study inclusion can be defined, locating existing programs  proved to be more challenging. There was no definitive source which identified inpatient programs. The lack of a standardized taxonomy (to define CAM vs. integrative medicine programs) was also a contributing factor to not easily identifying programs. 
In addition the reliability of the initial coded data and  final coded themes and categories  was dependent upon the researcher’s subject knowledge and limited by the lack of previous scholarly work in the subject area.
Further scholarly work in the field of integrative medicine and CAM programs will benefit the field and future researchers and may mitigate these issues.


1. Christianson, J. B., Finch, M.D., Findlay, B., Jonas, W.B., Choate, C. G., (2007).            

    Reinventing The Patient Experience, Strategies for Hospital Leaders. Chicago IL.             

    ACHE Management Series.

2. AHA Health Forum from (2008)
3. Bravewell from (2007)

4. NCCAM Publication, No. D158, from (2008)

5. Shi, L (1997).  Health Services Research Methods.  Albany, NY:  Thomson Learning.
6. Ransom, E.R., Joshi, M.S., Nash, D.B. (November 2008). The Healthcare Quality       
    Book: Vision, Strategy, and Tools, Second Edition.  Washington, DC:  Health
    Administration Press.