Chapter 1: Introduction
Over the past 30 years, public interest in and use of complementary and alternative medicine (CAM) systems, approaches, and products has risen steadily in the United States. Depending on how CAM is defined, an estimated 6.5 %1 to as much as 43%2 of the U.S. population has used some form of CAM.
Until recently, the primary response of Federal, state, and local health care regulatory agencies to this phenomenon was to restrict access to and delivery of CAM services to protect the public from unproven and potentially dangerous treatments. Since the early 1990s, however, scientific evidence has begun to emerge suggesting that some CAM approaches and products, when used appropriately, can be beneficial for treating illness and promoting health. As this evidence is collected and disseminated to the wider health care community and the public, it should provide a reliable basis for making policy decisions that will facilitate the public's access to safe and effective CAM approaches and products.
The White House Commission on Complementary and Alternative Medicine Policy (WHCCAMP) was established in March 2000 to address issues related to access and delivery of CAM, priorities for research, and the need for better education of consumers and health care professionals about CAM. The President's Executive Order No. 13147 establishing the Commission states that its primary task is to provide, through the Secretary of Health and Human Services, legislative and administrative recommendations for ensuring that public policy maximizes the potential benefits of CAM therapies to consumers.
Overview of the Commission's Mission and Activities
Specifically, the Commission's mission is to address:
To accomplish its mission, the 20-member Commission solicited expert testimony at its 10 meetings, which were held in various locations in and around Washington, D.C. between July 2000 and February 2002. At the WHCCAMP meetings, clinicians, researchers, medical educators, regulatory officials, policymakers, practitioners, and others were asked to provide recommendations regarding Federal policies related to CAM and documentation to support those recommendations. The Commission meetings were initially focused around four primary areas:
The Commission also solicited public testimony on these topics during its meetings as well as during a series of four Town Hall meetings held at various sites around the country. Overall, the Commission heard from approximately 1700 consumers, professional groups, societies, and health care organizations interested in Federal policies regarding CAM. Commissioners also visited several medical institutions and CAM clinics throughout the country to observe how CAM and conventional health care providers in integrated and collaborative care settings.
During its deliberations, the Commission came to the conclusion that, in addition to the areas covered by the Executive Order, two other issues needed to be discussed and addressed in order to accomplish the four primary goals. The first is the need to evaluate the possible role of CAM approaches in supporting health and wellness. The second is the need for a centralized coordination of Federal efforts regarding CAM. The Commission also recognized early into the discussions of its charges that not only were the four topics very complex, but time and resources were inadequate to address these topics in as much depth as each topic needed.
In developing recommendations, Commissioners divided into eight work groups formed around specific topics areas, e.g., education and training, research, information dissemination. Each Commissioner served on at least two work groups. The work groups' recommendations were presented to the whole Commission, discussed, and used as the basis for developing final recommendations.
Guiding Principles of the Commission and Linkages with Other Health Care Reform Efforts
Based on its mission and responsibilities, the Commission developed 10 principles to guide the process of making recommendations and to shape the recommendations themselves:
These Guiding Principles are remarkably consistent with the 10 rules for health care reform listed the National Academy of Sciences' Institute of Medicine (IOM) report on ways to improve health care in the 21st century (see Appendix B). That report, Crossing the Quality Chasm: A New Health System for the 21st Century, found that the nation's health care industry has "foundered" in its ability to provide safe, high-quality care consistently to all Americans, but particularly to those with chronic conditions.3 The IOM report recommended that clinicians, health care organizations, and purchasers need to do a much better job of focusing on and improving care for common, chronic conditions such as heart disease, cancer, diabetes, and asthma, which are now the leading causes of disability and death in the United States and consume a substantial portion of health care resources. The IOM report also recommended some specific health care reforms, including better mechanisms for communication between patients and their health care providers, increased cooperation among clinicians, a significant expansion of the evidence base for care, improved safety, and improvements in the dissemination of health care information to patients.
The Commission's guiding principles also are consistent with the U.S. Department of Health and Human Services' most recent 10-year health objectives for the Nation. These objectives are embodied in the report Healthy People 2010: Understanding and Improving Health.4 The two overarching goals of Healthy People 2010 are to: 1) increase quality and years of healthy life, and 2) eliminate disparities in access to health care. Healthy People 2010 enumerates 28 focus areas to which these two overarching goals are to be applied. Among these 28 focus areas are several that are analogous to the Commission's Guiding Principles, including:
Healthy People 2010's focus areas are especially directed toward improving access to and delivery of high-quality health care services for people with chronic, debilitating conditions, such as arthritis, cancer, back pain, and HIV infection. As noted in subsequent chapters, individuals with these conditions are frequent users of CAM practitioners and practices. Thus, the Commission's focus on improving the quality of care for those with chronic conditions by increasing access to safe and effective CAM systems, approaches, and products, potentially could have a significant impact on Healthy People 2010's goals for these costly, debilitating conditions.
Crossing the Quality Chasm and Healthy People 2010 emphasize better allocations and uses of existing conventional health care technologies and resources to address heath care reform. The report addresses ways in which resources and technologies that have not been part of the mainstream and that have not been applied to these problems on a large-scale basis may have a beneficial impact on reform of the health care delivery system and on the promotion of health and the prevention of illness.
In a group as diverse as the members of this Commission and a field as diverse as CAM, it is not surprising that areas of significant disagreement, particularly about tone and emphasis, remained to the end. In particular, several Commissioners were concerned that the report needs to state even more clearly than it already does that most CAM interventions have not yet been scientifically studied and found to be either safe or effective.
Some Commissioners suggest that because the Report makes so many recommendations about including CAM practices in a variety of areas, it may imply to some readers that more has been shown to be safe and effective than evidence yet indicates. Some Commissioners believe there is or may be an unstated ethos throughout the document that could be construed that many, if not most, CAM modalities are beneficial. Adding the qualifiers "safe and effective" helps, but the fact that the report makes so many recommendations may imply that more have been shown to be safe and effective than evidence yet indicates. None of the Commissioners want the report to be interpreted in these ways.
Although most CAM modalities have not yet been proven to be safe and effective, it is likely that some of them eventually will be proven to be safe and effective, whereas others will not. Thus, some Commissioners have agreed to many recommendations that they believe are premature in hopes that it may be useful to lay out a road map and context now to guide research and policy decisions over the next several years as more science and other information become available.
The question is not, "Should Americans be using complementary and alternative medicine modalities?" as many--perhaps most--already are doing so. For the most part, however, they are making these choices in the absence of valid scientific information to guide them in making informed and intelligent choices.
Many of the commissioners agree with the editors of The New England Journal of Medicine who stated in 1998: "There cannot be two kinds of medicine--conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted."5 But this presumes that sufficient funding is available for rigorous testing.
All the Commissioners believe that substantially more funding for CAM research is needed to help citizens understand the benefits and the liabilities of various CAM modalities and approaches, especially those that are already in widespread use and those that have the greatest potential for addressing the nation's most serious health care problems. They understand the limitations of science but also its power. They also know how difficult the obstacles can be in conducting good science.
Good science can help sort out what is true from what is not, what works from what does not, for whom, and under what circumstances and which conditions. Well-designed scientific research and demonstration projects can help to determine which CAM modalities and approaches are clinically effective and cost effective, as well as the mechanisms involved. Americans can then make more informed and intelligent decisions about their own health and well-being.
Some modalities of conventional medicine are widely used and some are being reimbursed but have not been proven to be either medically effective or cost effective, and some have side-effects that may be more harmful than many CAM modalities. However, the Commissioners believe and have repeatedly stated in this Report that our response should be to hold all systems of health and healing, including conventional and CAM, to the same rigorous standards of good science and health services research. Although the Commissioners support the provision of the most accurate information about the state of the science of all CAM modalities, they believe that it is premature to advocate the wide implementation and reimbursement of CAM modalities that are yet unproven.
Also, the Commission as a whole is concerned that the report, in using the term, CAM generically brings well established modalities under the same umbrella as those with little or no scientific evidence. The report does its best to distinguish in its recommendations between those proven safe and effective, such as exercise, nutrition, and stress management, and those that are not. But the Commission recognizes that this distinction may not always be completely clear. The Commissioners want to state in the Introduction the importance of this distinction and the role of research as the crucial instrument for determining what is safe and what is not, as well as what works and what does not.
Overview of Remainder of Report
In addition to describing the use of CAM by people with chronic conditions, Chapter 2 also presents an overview of the recent history of CAM in this country, its current status, and its prospects for incorporation into the nation's health care system.
Chapter 3 addresses the need for research coordination at the Federal level and with new directions and opportunities for CAM research.
Chapter 4 covers issues surrounding the education and training of conventional and CAM health practitioners and ways to enhance communication and collaboration among them.
Chapter 5 addresses the need for better approaches to developing and disseminating timely, accurate, and authoritative information on CAM, including dietary supplement labeling; the Federal Government's role in this process; and, strategies for promoting public-private ventures.
Chapter 6 discusses access to and delivery of CAM practices and ways to facilitate this process, including licensing and regulation.
Chapter 7 discusses the coverage of and reimbursement for CAM services and products by third-party payers, including the need for uniform coding strategies to make it easier for payers to reimburse for CAM services.
Chapter 8 contains information and recommendations on issues related to the potential role of CAM in wellness and health promotion programs and strategies for advancing this process.
Chapter 9 details the Commission's discussions and recommendations regarding the coordination of Federal CAM efforts.
Finally, Chapter 10 contains lists all of the recommendations and action items contained in this report.