Nancy Sudak, MD became known nationally as a leader in the board certification of integrative holistic medical doctors and then as the founding executive director of the Academy of Integrative Health and Medicine (AIHM). In these roles, Sudak knew the challenges of sustainability for integrative medicine models in large delivery organizations. So when she left AIHM, she developed an opportunity in a large upper Midwest system to create and prove an model. Now, two years plus into her experiment that is now a growing enterprise, Sudak has strategies to share in what she continues to view as a way to “normalize” the delivery of integrative medicine as a consultative practice in a large delivery organization.
I reached Sudak in her Duluth, Minnesota clinical space. She is part of the 15 hospital, 74 clinic Essentia Health. The system was stitched together from many Catholic and other non-denominational hospitals. Sudak first got involved there in 2015, helping bring in integrative luminaries like Scott Shannon, MD, Robert Bonakdar, MD and David Riley, MD to offer grand rounds. Sudak found remarkable support for integrative health from Essentia leaders and began a deeper conversation.
One step was to explore the nearby Allina integrative model led by the Penny George Institute, and powerfully backed by philanthropy. Sudak wanted something that could stand on its own feet, fast, and that might be developed anywhere: “We were determined to create a financially viable business model that would not rely heavily on philanthropy for ongoing operations.” Sudak started at Essentia in October 2016.. Forty percent of her time is currently set aside for administration and relationship building to network inside the system. They partnered her with the support on an administrator, Kathy Beeksma, RN, BSN, to whom Sudak gives great credit. Here is an edited version of our interview.
Integrator Integrator: So what is the size of the operation? How did it evolve?
Sudak: I began working clinically in March of 2017. That summer we brought in our first acupuncturist and an RD who has specialized training in functional nutrition. The next May – in 2018 – we brought in a family nurse practitioner and another physician in November. This year we’ve added a pediatrician and two additional acupuncturists. All these staff had significant integrative medicine or functional medicine training, or both, before they started. One had just finished an integrative medicine fellowship with Jeanne Drisko [MD] at the University of Kansas Medical Center.
Integrator Integrator: Where are you located? What is the facility like?
Sudak: We didn’t want to develop a high cost spa-type model. Our model weaves integrative health into existing clinic facilities. The initial integrative health department is located within the walls of the internal medicine area of one of Essentia’s busy clinical buildings. As we’ve grown, we’ve spread into additional sites – an oncology outpatient clinic downstairs and a neighborhood family medicine clinic. So the up-front cost is relatively low. We have worked on a shared staff strategy. Many of the clerical and medical support staff work partly for integrative Health, and partly for other co-located operations – for internal medicine, oncology and a family medicine freestanding clinic.
Integrator Integrator: What does the space feel like?
Sudak: We have worked to create a healing environment with simple and affordable measures. It doesn’t cost much to lower lighting, put music in some rooms, use colorful tapestries and soulful artwork, and produce inviting patient handouts. We serve herbal tea to patients upon their arrival. Our experience is that it really doesn’t take much to help them feel comfortable and know they are in a special space within an otherwise conventional clinical setting. Some of them actually comment that they feel like they are in a spa.
Integrator Integrator: What is the hiring model – are people salaried, or is compensation production based?
Sudak: We’re all salaried. The acupuncturists prefer 80% time. The others are 60% to full time. We have a mix of salary and productivity-based compensation in the system, but we’re strictly salaried in the integrative health department.
Integrator Integrator: That’s good – in that the salary basis diminishes the incentive to hold onto patients. Then let’s talk income side. How are you paid – how does it work inside the system?
Sudak: Our practice is consultative. We are mainly positioned as a resource for other practices in the system. I would estimate that 50% of our patients who see the physician-nurse practitioner team for consultations and follow-up are from referrals and the other 50% are from word of mouth or the limited promotion from the system. Other than a featured infomercial that has aired a few times on local television, we haven’t needed much marketing. I was booked out months ahead of time within the first year, and that became problematic because it discouraged physicians to refer to us. The acupuncture service has grown mostly from referrals, which are encouraged to help ensure coverage.
Integrator Integrator: Since you are this deeply located inside of Essentia, the business model must be insurance.
Sudak: We’re entirely insurance based. Medicare doesn’t cover acupuncture, so we send patients who have Medicare to our community practitioners of Oriental medicine, but private insurers here in Minnesota tend to cover acupuncture for a significant number of indications. Medicare will not cover medical nutrition therapy from our registered dietitian unless patients have chronic kidney disease or diabetes but private insurance tends to cover these services reasonably well for more indications. Medicaid coverage for acupuncture is robust In Minnesota but not Wisconsin. We bill as primary care clinicians, and follow our denials closely. We’ve not seen any denials for the services of the consulting physicians-nurse practitioner team. And we bill strategically, by time. We have more 99215’s than others do, I have learned. I’ve been audited, but had a zero percent error rate. We take fastidious notes, and meet all the criteria for time-based coding, so we feel confident that we on firm footing. We also have great support from people in our coding and compliance departments, with whom we work closely.
Integrator Integrator: How about things like laboratory fees – and people on Medicare for whom acupuncture or medical nutrition might be good but who have no coverage?
Sudak: We do order a lot of lab. We can garner a lot of meaningful information from conventional tests. Interestingly, a lot of Genova Diagnostics tests are covered by Medicare but not by private insurers. Sometimes patients simply have to pay out of pocket, if they can afford it. But other patients are so financially challenged that acupuncture, functional medicine labs or supplements wouldn’t even enter the conversation. We do make use of empiric treatment for some conditions. I had good training in working from a perspective of scarcity during my years working for a federally qualified community health center.
Integrator Integrator: It would be interesting – if you had a large enough population sample – to check the outcomes of patients with whom you had the use of lab and those on whom your were working from more of an empiric base. Since your patients seem to be liking the services, are any of them gravitating to you, and away from their referring doctors? That can be a problem.
Sudak: Sometimes. It’s challenging. People are so much sicker than they used to be. Though we aren’t available as primary care practitioners, we find ourselves with panels of patients who require ongoing care–much like a pulmonologist or nephrologist who treats patients continuously in addition to their internists or family docs. Usually if I end of handling some issue that is not exactly what they were referred for, I will send a note to the primary clinician just letting them know. No one has indicated it to be problematic, and they usually appreciate the communication.
Integrator Integrator: It will be nice if insurers and other professionals appreciated the specialty and complexity of health creation. Do you have demographic data?
Effectively, given the cash issues for some patients, you have a sort of two- tiered treatment plan.
Sudak: We don’t have that data, though we are tracking symptom outcomes with questionnaires. I have found over the years that a primary problem in medicine is that patients with the fewest resources tend to have poorer outcomes when their basic foundational needs such as we provide in our integrative health service go unmet. I feel very strongly that this is ultimately medicine that should be available to everyone.
Integrator Integrator: So then, let’s turn to your core proposition. Is the model sustainable – and to be clear, what all is considered on the expense side. The making or breaking of business models at places like Continuum Health ultimately fell to what the financial people included on the expense side.
Sudak: We are heading toward it, and I believe we will have it with the additional physicians sharing the staff and overhead. This is including our share of all of the ancillary support services, all of our salaries and benefits, and all of our supplies. This doesn’t include any charge for space. But without that included, it looks like we are definitely on our way. We are cautious in our spending habits. And one way we are generating income for the organization that is external to the budget is through making high quality supplements available in our building’s pharmacy. We believe the mark up is compassionate on the consumer end.
Integrator Integrator: Do you feel limited with “integrative” including just your consult and the acupuncture and dietician services? What about chiropractic, massage – the services of naturopathic doctors – or things like mind body programs and group services? Or is this the dimension of what you see as the sustainable integrative service?
Sudak: Yes and no. The current model is built on the premise that all practitioners must be able to work within an RVU [Relative Value Units] system with insurance billable codes. I did not want to open up a department that relied on subsidies out of the box. We have explored adding chiropractic services, and haven’t added them in our department yet because we’ve learned that in order to break even, extremely high volumes of encounters per day appear to be necessary. That’s not a model we’re interested in embracing, as we are promoting unrushed and intentional experiences for patients. Essentia has begun to employ a few chiropractors in the West region and is closely monitoring the success, as I understand. We have two naturopathic doctors in our community, and we sometimes co-treat patients. Their services are strictly fee-for-service in Minnesota, so that’s not a good fit for our department. Massage is available in our fitness center already, and our organization does offer MBSR [Mindfulness Based Stress Reduction] programs. We are just beginning to offer group medical visits starting this month. We have wonderful community practitioner resources, and I recommend them often.
Integrator Integrator: In your note to me you spoke of “weaving” the integrative services. It seems a big metaphor for your strategy.
Sudak: The whole idea is that Integrative Health is just part of the furniture here. We’ve been purposeful in not being splashy or spa-like. We are attempting to convey the message that integrative care should be available to all without needing to be fancy. We have found that we can accomplish much with simple resources. As intended, we are inspiring some of our colleagues to learn about what we do and how they can start implementing some of these strategies – and through a philanthropic partnership with Miller Dwan Foundation we have been able to support some in their education. We have offered a grand rounds series twice since we’ve opened, and those have generated a lot of internal interest. I’ve been pleased by the responsiveness of other physicians and community members. Sometimes I feel like the chocolate-vanilla-twist of the conventional and integrative worlds. My fluency in both languages helps unite sometimes disparate schools of thought, which is designed to translate to better care.
Integrator Integrator: Thanks Nan. I’ll check back in later in the year to see if the trend moves fully into the black, and to discover whatever other changes you might have made.
Concluding note: For a field that marched into the light speaking of paradigm changes and of healthcare transformation, Sudak’s goal and methods of “normalizing” integrative care may seem more than a few steps off mission. No question, these integrative options and tools are carved back and more limited in this insurance dominated environment than many of the broader teams imagined in the early days of “CAM” integration. Yet at the same time, the new patient who comes to get integrative health care through this major delivery organization, Essentia Health, is finding that, at least in these offices, care that is quite different is indeed becoming normal. This could be a model for many. We will keep tracking it!
John Weeks is a writer, speaker, chronicler