October 31, 2013
Universal Single-Payer Health Care’s Envisaged Intersection with Natural Medicine: Part 3 of a 3-Part Series
Joie Meissner, ND
There are certain commonalities that are relevant to single-payer plans to state and nationally proposed plans. Of interest to natural medicine enthusiasts are those features of single-payer health care that pertain to private practice physicians and primary care providers, definitions which generally fit naturopathic physicians (NDs) in states that offer licensing. (hence forth known as licensed states)
- Single-payer plans seek to remedy the shortage of primary care providers.
- The enactment of single-payer plans tends to favor pay parity for primary care physicians as compared to specialists.
- Single-payer plans put an end to haggling with insurance companies who refuse to cover natural treatments or to pay providers in a timely manner.
- Single-payer proposals put forth by physician led advocacy groups leave their options open on decisions pertaining to which treatments should be covered and tend to favor more cost effective options.
In states that do not offer licensing to naturopathic physicians (also referred to as unlicensed states) these two definitions would not apply and hence the impact of single-payer on natural medicine in the unlicensed states would be somewhat less conspicuous than it would be in licensed states. However, even in unlicensed states, the passage and the steps leading towards the enactment and execution of single-payer legislation would be expected to allow for more movement in a direction that favors licensure in the states that elect to adopt a Medicare-style single-player model.
In licensed states, the consequences of single-payer plans for natural medicine and NDs can be predicted to vary according to how that state views NDs in terms of the definition ‘primary care physician’, how that state had viewed NDs and natural medicine prior to single-payer legislation and depending on the number of primary care physicians per person in that state. Depending on the degree to which natural medicine enthusiasts and naturopathic physicians become involved in the realization and enactment of a state single-payer system, the impacts to natural medicine and to NDs can be predicted to follow a dose-response curve; the more knowledgeable and involved the natural medicine community is the more likely it would be to benefit from single-payer legislation that may be in the future of Washington state health care.
The remainder of this article will focus on how the implementation of single-payer legislation in licensed states like Washington State could potentially allow for positive changes for NDs and natural medicine.
Naturopathic Physicians Are Included in Washington State Single-Payer WHST Legislation
As licensed health care practitioners, naturopathic physicians are included in the Washington State single-payer bill HB 1085, Washington Health Security Trust (WHST). (Refer to part-2 of this article for more details about the WHST)
The WHST Could Increase Patient Access to NDs and Natural Medicine beyond that of the ACA’s Medicaid Expansion
In Washington State, at present, only substances or treatments obtainable via prescription are covered by Medicare and Medicaid. Only Medicaid covers naturopathic physicians and but neither Medicare nor Medicaid reimburses for the majority of natural therapies. The Medicaid expansion could increase the ND patient pool for NDs who accept Medicaid.
However, ACA’s Medicaid expansion alone does not positively alter Medicaid reimbursement rates. Not all NDs will be able to afford to accept Medicaid. A single-payer plan could enhance reimbursement rates to primary care physicians, further incentivizing ND acceptance of Medicaid payment and thereby increase access of the economically challenged to ND services.
Because they are only able to access pharmaceutical treatments that they reject, many of the poor, elderly and disabled patients in Washington State are completely unable to access non-drug alternatives or are forced to choose between food and non-pharmaceutical options. A single payer system enhances the odds that natural medicines would be made more available and more affordable to those who currently find these treatments beyond their reach. This could make both naturopathic physicians and many non-pharmaceutical treatment options more affordable to poor, elderly and disabled patients who reside in our state.
Single-Payer Plans Seek to Remedy the Shortage of Primary Care Providers
This health care program’s emphasis on meeting the need to fill the current shortage of primary care physicians includes loan forgiveness programs for graduating medical students agreeing to enter primary care residencies and/or to work in underserved areas. It also increases funding for graduate medical education teaching programs in primary care; this includes ND training programs which, by law (at least in Washington State), are primary care medical training programs.
In states like Washington and other licensed states, naturopathic physicians could help meet the need for more primary care providers and loan forgiveness programs may help naturopathic physicians to set up practices or work in underserved areas which could help decrease ND student loan debt while at the same time allowing more patients greater access and freedom to have naturopathic physicians as their primary care providers.
By extending coverage to all the state’s citizenry as well as by ensuring that all licensed physicians would be covered under this plan, a single-payer plan could enlarge the ND patient pool thereby decreasing the number of patients that lack access to primary care providers and enhancing patient choice.
Single-Payer Plans Tends to Favor Pay Parity for Primary Care Physicians
Despite the similarity in the number of years of education, the type of training and amount of educational debt ND reimbursement rates from third party payers are typically 15-50% less than those for MDs performing identical services.
Projections have indicated that implementation of a single-payer system, would result in increased pay parity for primary care physicians with specialists. Washington State naturopathic physicians are defined as primary care physicians. Thus, increased pay parity for primary care physicians could greatly ameliorate or even potentially eliminate discriminatory reimbursement practice to NDs and other licensed primary care physicians. This could also allow naturopathic physicians to offer primary care services as a greater proportion of their practices and may also decrease the need for NDs to specify a niche/unofficial specialty in order to maintain financial solvency in urban areas where NDs are more concentrated.
Single-Payer Plans Put an End to Haggling with Insurance Companies Who Refuse to Cover Natural Treatments or Pay Providers in a Timely Manner
Doctors today are often hamstrung by the limited formulary and set of modalities that insurers will cover and by the added infrastructure necessary to collect their reimbursement from private insurers. At present, the status of health care as a for-profit endeavor results in decreased availability of certain types of providers and treatments, such as naturopathic physicians and to natural treatments that may actually be superior in many cases and are often less expensive than the ones for which private insurers want to reimburse. The added billing expense forced on physicians by the private insurance system takes resources away from the quality of care and the affordability of that care patients receive.
The user friendly aspects of single-payer systems especially for private practice physicians like naturopaths can be predicted to lead to an improvement in the quality of care that naturopathic physicians and most other private practice physicians can provide to their patients.
Under a Medicare style single-payer system, private insurance would be superfluous because everyone would be covered for their all essential medical care by the single-payer system. One of the consequences of not having to depend on the private insurance system for the reimbursement of naturopathic physicians would be that NDs would become less limited in the types of treatments that their patients can afford to use. Under a single-payer system the number and variety of treatments available to patients is predicted to substantially increase and doctors and patients rather than insurance companies would have a greater say in what treatment a patient can access.
For patients who submit their own claims hoping to receive reimbursement for naturopathic care their would be no time spent haggling over coverage issues with insurance companies who refuse to pay on valid claims. This would translate into more time that patients can devote to their own health care. With fewer resources expended dealing with the financial overhead of health care in a single-payer system there would be less need for physicians to act like billing clerks; this would lead to an enhancement in the quality of care that we can provide to our patients and that we as patients receive from their providers.
Potential for Increased Research Funding to Encourage the Use of Cost-Effective Natural Therapies
In addition to fostering policy decision making via participatory democratic process, one of single-payer’s aims is to control costs by for example, offering inducements such as increased research funding to encourage the use of cost-effective therapies such as efficacious natural therapies that are not patentable but may be less likely to lead to costly iatrogenic disease down the road. A number of natural therapies are frequently safer than certain drugs with high side-effect profiles that are currently used to treat the same conditions. Many of these treatment options are often preferred by both physicians and patients alike but are not reimbursed under the current private insurance system.
Single-payer’s accent on democratic decision making and cost control could allow for coverage of many natural treatments that naturopathic physicians recommend to their patients who currently must pay out of pocket for these treatments making these therapies more accessible to many more patients.
Selection of Covered Treatments under a Single-Payer Health Plan
At the national level, single-payer proponents such as Physicians for a National Health Program (PNHP) have proposed that “In general, coverage decisions will be made by the health care planning board or another public body. New kinds of treatments will be added to the benefits package over time as they are shown to be effective, including ‘alternative’ treatments.”  PNHP further proposes that the decision making body, the health planning board, would be a “public body with representatives of patients and medical experts.”,,
Proposed Decision Making Bodies could Include the Board of Naturopathy
On the state level, the Western Washington Physicians for a National Health Program (PNHP-WW) have set forth principles as part of their Washington State Alliance for Health Care as a Human Right objectives. One of these principles, principle # 7, states that: “Health care policy-making is decided through a participatory democratic process at all governmental levels.”
Therefore, based on both the national and state democratic framework, it has been suggested that the representatives from the Washington State Department of Health Board of Naturopathy could be included in our state’s health care planning board, the board responsible for making coverage as well as other policy decisions. It is also possible that Washingtonians could elect or have influence via appointment of elected officials regarding the representatives that could also be included in Washington State’s health care planning board.
Based on its current popularity in Washington State and on how many natural medicine supporters become involved, under a single-payer system, natural medicine would likely become much more readily available to patients who prefer more natural alternatives than they have access to at present. Moreover, presence of members of our state’s board of naturopathy on a single-payer system’s decision making body such as a health care planning board could allow for greater participation and integration of naturopathic physicians in health care decision making in our state.
The Term ‘Evidenced-based’ could be defined by the Health Care Planning Board
The lack of coverage of natural therapies is often based on the presumption that these therapies are not “evidenced-based” or that these therapies are“experimental”. This presumption is based on the lack of phase I-III randomized placebo controlled trials (RPCTs) or FDA clinical trials which are the standard by which drug therapies are “proved” to be “evidence-based” under the existing system. However, natural treatments currently have an unfair disadvantage compared to their pharmaceutical counterparts, namely, the fact that only the pharmaceutical and medical device industries can afford to finance the enormous costs of the RPCT, FDA studies.
Further exacerbating the disadvantage of natural treatments as compared to pharmaceuticals is the erroneous, a prior, assumption that off-label use of drugs is an evidence-based practice. Despite the RPCT standard, off-label uses of pharmaceuticals that are based only on conjecture concerning mechanisms or on anecdotal evidence alone is extremely widespread, making up a significant proportion of conventional treatments. Yet, there is no parity for natural non-patentable treatments that are supported by a body of research data demonstrating their efficacy.
The assumption that conventional medicine is evidence-based and natural medicine is at best based on only anecdotal evidence has not as yet to be born out in the literature and there is evidence to the contrary. Citing JAMA, Martin A. Makary MD, MPH. reports that 25% of conventional medical practice is evidence-based and the other 75% is “discretionary”.
At present, single-payer principles in Washington State also emphasize the use of ‘evidence-based’ medicine, but this term has not been rigidly defined as yet. Under a single-payer plan the term ‘evidence-based’ could be defined in any number of ways based on the determination of the health care planning board.
The following are just a few examples of how the term ‘evidence-based’ could be defined under a single-payer health care plan in licensed states like Washington:
- The term ‘evidence-based’ could be defined solely as those therapies proven efficacious by phase I-III clinical trials
- The term ‘evidence-based’ could be defined as those therapies proven by meta-analysis or by a quorum of RCTs
- The term ‘evidence-based’ could be defined as therapies proven by historical/traditional use or by a risk-to-benefit quotient assessment
- The term ‘evidence-based’ could be defined more broadly as a combination of; individual clinical expertise, best external evidence and patient values and expectations depicted as a Venn diagram model by the Cochrane Collaboration.
Thus, the term ‘evidence-based’ and/or simply the covered therapies themselves could ultimately be chosen based on a consensus style or democratic decision making process that the health care planning board of a state single-payer system determines.
In the highly unlikely event that for example, a very strict definition of phase I-III FDA CTs is chosen, the health care planning board would have to eliminate coverage of all off-label use pharmaceuticals. If such a definition were chosen by a state single-payer health care planning board it would mean discontinuing coverage of thousands of drugs that have off-label uses. If such an improbable coverage decision were made, the health care planning board could elect to fund studies on the off-label uses of drugs or the drug companies would fund these studies.
Based on the likelihood of the selection of an alternative definition of the term ‘evidence-based’, under a single-payer plan, an argument would thus, be strong for increasing NIH funding to phase I-III CTs for promising natural therapies.
Presently, there is one naturopathic physician on the board of directors of PNHP-WW, a physician led Washington State single-payer advocacy group. The more naturopathic physicians and natural medicine proponents become involved in single-payer advocacy the more likely that the definition of the term ‘evidence-based’ would be defined to reflect descriptions that encompass natural, non-patentable therapies and the more probable that these therapies would be to be covered.
The possibility for NDs to participate in board decision making could help to integrate conventional and naturopathic medicine under one roof, as different flavors of the same discipline, that of medicine.
Dose Response Relationship:
How Natural Medicine May Fare under the Single-Payer Plans that Are Being Proposed Depends on What We Know
As far as the universal single-payer plans that are being proposed, natural medicine has great potential, a potential that will depend in part, upon how actively NDs and natural medicine supporters participate in the ascension, realization and evolution of our state’s single-payer health care plan. It is therefore important that NDs become informed on this issue.
Single-payer systems that have been proposed by a number of advocacy groups could benefit physicians and patients who use natural medicines in the following ways:
- Elimination of private insurance hassles over billing would enhance the quality of care to patients of naturopathic physicians and lead greater patient and physician choice regarding therapies they can use.
- Naturopathic physicians could become part of the nation’s solution to the shortage of primary care providers. The possibility for ND presence on state or federal single-payer loan forgiveness and residency programs could lead to decrease ND student loan debt while at the same time allowing more patients greater access and freedom to have naturopathic physicians as their primary care providers leading to a potential decrease in the numbers of patients that lack access to primary care providers.
- The fact of ND inclusion in our state’s single-payer bill strongly increases the prospects for both naturopathic physicians and many non-pharmaceutical treatment options becoming more affordable to poor, elderly and disabled patients who reside in our state.
- Single-payer’s objective of decreasing the cost of covered treatments could translate into increased research funding to encourage the use of cost-effective natural therapies.
- The potential for ND participation in the single-payer plan’s health care planning board could help level the playing field for natural therapies thereby increasing patient access to these therapies.
- The prospects for ND participation in a single-payer plan’s decision making body could also enhance pay parity of naturopathic physicians with that of conventional medicine.
- The presence of ND involvement increases the chances that the definition of the term ‘evidence-based’ would be defined to reflect descriptions that encompass natural, non-patentable therapies and it also increases the probability that natural therapies would be to be covered under a single-payer health care plan in Washington State.
Conclusion of the 3-Part Series
There is a dose-response relationship between the level of understanding that naturopathic physicians and all people living in this country have regarding the basic concepts involved our health care crisis and our ability to solve our health care system problems. The more we learn about this issue the more able we will be to trust our diagnosis of the problem including its causes and its prospective cures.
We have already taken the first step on the road to health. That step is docere or doctor as teacher. By having tuned in to absorb the information in this 3-part article, we have all become the doctors of our own destiny; we have all become healers of the crisis in American health care.
Special Thanks to: Sherry Weinberg, MD, Don Bunger, MEd, Helen Thorsen CDP, Don Mitchell, MD, Jim Squire, MD, Marti Schmidt, JD, David McLanahan, Betty Capehart, MSc, Dana Iorio, ARNP, Kathleen Myers, DDS, Kathleen Randall, MA, all my patients.
Geyman, John M.D. PNHP Past President. “What does PNHP have to say about the primary care workforce shortage?” Physicians for a National Health Program. Single-Payer FAQ. http://www.pnhp.org/facts/single-payer-faq#primary-shortage Web. 14 Apr. 2013.
 May, Robert N.D. Executive Director Washington Association of Naturopathic Physicians (WANP). Telephone interview. 12 Apr. 2013.
Woolhandler, Steffie M.D. “Under single payer, won’t physician incomes go down?” PNHP. “What will happen to physician incomes?” Single-Payer FAQ. http://www.pnhp.org/facts/single-payer-faq#income Web. 14 Apr. 2013.
 Physicians for a National Health Program. “What about alternative care, will it be covered?” Single-Payer FAQ. http://www.pnhp.org/facts/single-payer-faq#alt_care Web. 14 Apr. 2013.
 Physicians for a National Health Program. “What about alternative care, will it be covered?” Single-Payer FAQ. http://www.pnhp.org/facts/single-payer-faq#alt_care Web. 14 Apr. 2013.
 Physicians for a National Health Program. “How will the Health Planning Board operate?” “Who will run the health care system?” Single-Payer FAQ. http://www.pnhp.org/facts/single-payer-faq#board Web. 14 Apr. 2013.
 Physicians for a National Health Program. “Who will run the health care system?” Single-Payer FAQ. http://www.pnhp.org/facts/single-payer-faq#run_system Web. 14 Apr. 2013.
Physicians for a National Health Program. “Who will run the health care system?” Single-Payer FAQ. http://www.pnhp.org/facts/single-payer-faq#run_system Web. 14 Apr. 2013.
Physicians for a National Health Program Western Washington. Working Draft Washington State Alliance for Health Care as a Human Right. 24 Nov. 2012. E-mailed to author by Donald Mitchell M.D. 18. Feb. 2013.
Makary, Martin A. M.D., M.P.H. “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care.” (Bloomsbury) Public Lecture Downstairs at Town Hall Seattle. 15 Nov. 2012.
 Physicians for a National Health Program Western Washington. Working Draft Washington State Alliance for Health Care as a Human Right. 24 Nov. 2012. E-mailed to author by Donald Mitchell M.D. 18. Feb. 2013.
 The Cochrane Collaboration. “Are scientific methods used to determine which drugs and procedures are best for treating diseases?” Evidence-based health care and systematic reviews. Updated: 9 Nov. 2012. http://www.cochrane.org/about-us/evidence-based-health-care Web. 14 Apr. 2013.
How Natural Medicine May Fare in the Universal Single-Payer Plans that Are Currently Being Proposed
Joie Meissner, ND
April 30, 2013 version available upon request
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