Unlocking the Value of Functional & Integrative Medicine In The COVID Era
A Web of Problems — and an Important Opportunity
COVID-19 has produced a number of pressing challenges that threaten the health and safety of the population while at the same time, significantly compromising functional and integrative medicine practices across the country.
Shuttering of Functional and Integrative Practices – An Avoidable Tragedy
As the CDC directed people to limit healthcare visits to emergency needs, the calendars of most practices were cleared for an indefinite amount of time. Aside from the obvious economic threat to their practices, the sidelining of this substantial and highly skilled healthcare workforce — and the separation of these practitioners from their patient populations — is particularly dangerous at this time for several reasons:
- The average functional/integrative medicine patient is 44 years old and has three disease diagnoses, including a significant concentration of cardiovascular, metabolic, and autoimmune disease burdens.
- This multi-chronic patient group comprises the highest COVID-19 complication and mortality risk segment of the working-age population and requires the most attentive professional support possible both to protect themselves from the virus and to mitigate its effects if infected.
- These health-challenged patients are also at greatest risk of additionally compromised health status in the event of disrupted care regimens.
It is an obvious tragedy to have thousands of healthcare practitioners sidelined and separated from their patients for the duration of the largest health crisis in modern history. However, this tragedy is compounded by the fact that these particular practitioners are uniquely positioned to fill a glaring unaddressed need that is specific to COVID-19.
To date, the care guidelines that have emerged for COVID-19 have focused heavily on treating patients once they have arrived at the hospital. Meanwhile, infected patients, or those who suspect they have the virus, and are not yet hospitalized are left with almost no guidance at all on how to tend to their own health at home before their symptoms may force them to the emergency room.
Advice is limited to self-isolation, hand washing, hydration, and watchfully waiting for dangerous symptoms to emerge that would prompt them to utilize emergency care.
The Critical Need for Functional & Integrative Practitioners to Fill
Functional and integrative medicine practitioners are the best trained professionals in the health system to address the needs of asymptomatic and symptomatic patients prior to the possible need for hospitalization. Extensively trained to provide personalized guidance to patients in the use of nutrition, nutraceuticals, and lifestyle to prevent, reverse, and potentially blunt the effects of chronic disease, no one in the healthcare system is better suited to support the great majority of people infected by, or seeking to avoid, COVID-19.
Properly equipped to engage virtually with patients, these practitioners could not only fill this void for patients during this crisis, but also expose new audiences, and the broader health system, to the value and utility of a systems-based approach to managing health.
More possible than ever before
As dire as the situation is, COVID-19 has accomplished in a matter of weeks what would have taken another decade of lobbying to create the opportunity for practitioners to serve their patients remotely during this crisis.
Through the relaxation of a number of key telehealth regulations and payer policies, the stage is now very well-set for practitioners to sustain their practices by providing invaluable service and support to both existing patients and others in their communities and beyond.
Four Steps to Practice Sustainability & Impact During and Beyond the Pandemic
With the proper tools in place, equipping functional medicine practitioners to actively contribute to the effort to contain the pandemic requires very little in terms of time and cost. The process can be broken into four clear steps:
Step 1. Rapidly implement telehealth tools.
With great urgency, functional and integrative practices that have not put telehealth tools into place already, must transition from their brick-and-mortar operating models to virtual patient care. There has never been a more opportune time to do this. Ready-to-use tools are available and affordable, and the telehealth regulatory environment has suddenly become extremely accommodating to physicians practicing beyond the borders of the states in which they are licensed.
The federal and state governments are continuing to announce new and more flexible ways for doctors to reach patients and contribute to addressing the COVID-19 crisis. Given this ongoing flow of regulatory activity, much of which will be likely reversed in the future, practitioners are advised to remain current on their state-level COVID-19 actions and to take the necessary steps to manage their liability.
While there is much to consider when altering a practice model, now is a time to favor speed – recognizing that the time will come for deeper thinking about the degree to which practitioners will wish to permanently maintain their virtual models. For now, at a minimum, practices need to equip themselves to: schedule a virtual visit (possibly allowing patients to self-schedule); conduct a video visit; and bill and collect for a virtual visit.
It is important for practitioners to recognize that in the current climate, the implementation of telehealth tools is a necessary, but likely insufficient measure to enable their practices to contribute the full extent of its value in the COVID-19 crisis.
Step 2. Define the COVID-19 value proposition for patients who are not in the hospital.
Practitioners must define their role in the crisis for patients and translate that role into a virtual, COVID-era clinic offering to engage and serve their communities. The approach to accomplishing with the greatest possible impact for patients and for the practice is not intuitive.
Most practitioners clearly recognize that they have valuable advice to offer anyone seeking to mitigate the risks or the likely impact of infection. Many have distilled that advice to writing and broadcast their guidance in the form of thorough and thoughtful email newsletters to patients and others.
While well intended, this grossly under-represents what functional medicine practitioners have to offer. And this method of dispensing advice in the absence of an active support proposition is of little real value to patients – and almost no value at all to the practice.
An alternative approach that practitioners should consider both for COVID-19, and other conditions and health objectives in the future, is to bundle their services into an episode of care that tracks and addresses the needs of the patient from the initiation of their request until a defined end-point at which, ideally, the targeted health objective is met.
COVID-19 represents an opportune starting point for practitioners who see the merits of this approach. For the great majority of people, the virus is an acute infection that largely resolves in a matter a single month.
There are an understood set of constraints for healthcare services supporting patients outside of the hospital in this context. The service must be delivered remotely. It should provide a persistent sense of connection to an expert who is following the case and providing personalized, empowering guidance. Given the scarcity of testing, it must tolerate a degree of ambiguity with respect to a conclusive diagnosis.
With no known treatment for COVID-19, patients are intuitively drawn to the notion of fortifying their own bodies to prevent it or to blunt its effects if infected. Consequently, the service must empower the patient with potent steps that they can take from their homes to achieve their desired objective.
For this reason, functional medicine practitioners are very well positioned to use their extensive training in the personalization of nutrition and lifestyle to create a highly differentiated value proposition for consumers, and potentially to employers, that today, has no competing alternative.
To satisfy these criteria, the episode must integrate certain new tools and technologies beyond the basic telehealth platform:
- An intake questionnaire tailored to COVID-19, its known risk factors, and the current reality of lifestyles suddenly taking place in the confinement of the home that may increase risks.
- A simple, objective way to assess COVID-19 risk prior to testing and that accounts for the ever-expanding base of knowledge pertaining to the virus.
- An efficient way to passively follow patient symptom progression. Each of these tools have now been created, and they are free and easy to use.
- A well-defined, nutraceutical and lifestyle protocol for patients that can be easily and affordably implemented in the home.
- COVID-19 and antibody testing. The scarcity of kits, limited processing capacity of labs, and the FDA’s appropriate response to the irresponsibility of direct-to-consumer testing companies in the early phase of the pandemic have slowed the ability of physicians to order home-collection testing on behalf of patients. As this issue resolves, the most responsible first approach to be taken with home-collection tests is to permit their use when ordered through a physician and with appropriate, virtual supervision by a healthcare professional of the sample collection.
- Home testing to quantify modifiable, lifestyle associated risks. COVID-19 has heightened public awareness of the liability of chronic disease and associated risk factors such as elevated blood sugar and inflammation levels and low levels of Vitamin D. Ironically, for many people, the shelter-in-place and quarantine mandates are protecting them from exposure to the virus while simultaneously catalyzing lifestyle disruptions that increase the risks of serious complications of the virus. Practitioners need access to an affordable home test to quantify these measures and thereby motivate and direct the efforts of patients to make the highest impact lifestyle changes.
Step 3. Package and price the episodes of care for COVID-19.
With bundled episodes of care defined, and the tools in place to implement them, practices must then package and price these episodes for purchase by consumers, and potentially by employers.
Approaches to pricing will vary based on practice revenue models, however, when possible, practitioners should strongly consider bundling the episodes into defined packages for patients rather than charging patients by the encounter or unit of time or service.
There has never been a better circumstance in which to apply this pricing structure – especially for practices that do not contract with or bill third-party payers. In the effort to minimize the financial impact of COVID-19 on consumers, an important accommodation has been made that is relevant to functional medicine practitioners. Section 3701 of the CARES Act allows a high-deductible health plan (HDHP) with an HSA to cover telehealth services prior to a patient reaching the deductible. (You may find a thorough listing of the key telehealth provision of the CARES Act from the American Telemedicine Association.)
With this change in effect, along with a host of others from health insurance providers in response to COVID-19, many patients, if given the proper documentation, can submit their own out-of-network claims and receive reimbursement for virtual care.
This enables physicians providing a bundled, COVID-19 related episode of care to deconstruct the bundle into its reimbursable components and equip patients with the documentation to reimburse themselves in full, or in part for whatever they pay the practice for covered features of the care package. This does not restrict practices from setting their own bundle pricing.
Practices that are contracted with payers may take a different approach to bundled pricing. As they are obligated to bill payers for covered services, their bundled price should be documented and account strictly for non-covered services included in the bundle. This is a well-tested approach to compliantly capturing the fair value of high-touch health services used for nearly 20 years by concierge physicians in the “fee for non-covered service” model.
Step 4. Announce the service to patients and the public.
Having filled a significant gap in care, practices must then announce the availability of their Virtual COVID-19 Clinic to their patients and extended communities. While this is a familiar marketing and communications exercise, the climate created by the pandemic has likely opened new opportunities for reach and impact.
Depending on their objectives for patient volume, practitioners should consider three new possibilities as they plan their outreach:
- In light of the relaxation of telehealth regulations for the COVID-19 crisis, practices may engage patients outside of the state in which they are licensed. With this in mind, practices should consider inviting patients to refer family members and friends to utilize the Virtual COVID-19 Clinic as needs arise.
- Given the uniqueness of the proposition, its timeliness, and the fact that it fills a distinctly unmet need, practices should consider introducing their programs to local media.
- Practices should consider outreach to area employers. While under ordinary circumstances, it is difficult for independent practices to engage directly with employers, circumstances surrounding the pandemic appear to have opened the minds of business leaders to creative approaches to meeting the needs of their employees and other health plan members.
Seizing the moment
Functional and integrative medicine practitioners are in the right place, at the right time, with the right training to create real value for their patients and communities.
Among the greatest challenges faced by the functional and integrative medicine community in its efforts to broadly impact the practice of medicine is the reality that a root-cause approach to addressing disease lowers the trajectory of healthcare consumption. Almost regardless of its particular application, widespread adoption of functional medicine threatens the economic interests of one or more entrenched, legacy stakeholders in the healthcare system.
As a result, the functional medicine field has a long history of being confronted with resistance and barriers from these stakeholders often invoking insurmountable or irreconcilable arguments related to evidence and/or standards of care.
The COVID-19 crisis has created a window of opportunity in which governments and healthcare systems around the world have been swept into a race to contain a new virus with no known cure, no proven treatments to mitigate its effects, and no vaccine. In this rare instance, there is no evidence base to guide treatment, no standard of care against which to judge new approaches, and no resistance to safe and plausible approaches to containing the impact and spread of the disease.
In addition, the virus, along with the media, has shined a permanent light on the dangerous, personal liability of chronic disease – even if it is “well-managed.” Emerging from this crisis, it is reasonable to expect an unprecedented degree of interest and engagement in reversing, rather than managing the lifestyle-born, chronic conditions that have created such pronounced vulnerabilities for many of those infected by COVID-19. Culture and health values will likely have shifted in a direction that favors the root-cause approach of functional medicine.
The barriers are down, and the world awaits those with a safe and effective approach to address the pandemic. There has never been a more opportune time to impact the health system through a systems-based approach to managing health.
To learn more about how to put these 4 steps into action, visit VirtualPractices.org - a 100% free resource to support healthcare practitioners in developing a thriving virtual practice.
