White House CAM Commission Delivers Final Report

After two years of various meetings, hearings and site visits, and after listening to written and oral testimony from more than 1,000 members of the health care community and the general public, the White House Commission on Complementary and Alternative Medicine Policy has issued its final report to the Department of Health and Human Services. The inch-thick document, which the Commission's chair calls "a ground plan for ways to integrate complementary and alternative medicine approaches to health care into the system,"¹ lists more than 100 recommendations and courses of action, many of which emphasize information and education as the keys to making intelligent, objective decisions about health care. It also suggests that the federal government will play an increasing role in the evaluation and implementation of certain forms of complementary and alternative medicine.

The Commission's recommendations are divided into six categories, covering nearly every aspect of complementary and alternative medicine. Among the more noteworthy suggestions:

Research

• Federal agencies should receive increased funding for clinical, basic and health services research on CAM. Financial support should be increased at all levels - federal, state and private - to expand and evaluate CAM faculty, curricula, and program development. Suggestions include expanding federal loan programs to include CAM students and making them eligible for the National Health Service Corps Scholarship program.
• The Agency for Health Care Research and Quality (AHRQ) should "expand its evidence-based practice center systematic reviews on CAM systems and treatments for use by private and public entities."
• The National Center for Complementary and Alternative Medicine (NCCAM), along with AHRQ, should issue "a comprehensive, understandable, and regularly updated summary" of current evidence on the safety and efficacy of CAM treatments for both health care practitioners and the public.
• Congress and the White House should investigate "legislative and administrative incentives" that would spur CAM research by the private sector.
• Increased efforts should be made to improve dialogue between CAM providers and conventional medical practitioners.
• The federal government should support research - including population-based studies - to learn more about why people use CAM; how they determine the safety and effectiveness of the products they use; and what they find satisfying (or unsatisfying) about CAM products and practices. Federal, private and non-profit organizations should also support new and original CAM research in areas designed to improve self-care, promote wellness, and answer core questions that might expand the overall understanding of health and disease.

Several recommendations were aimed specifically at the quality of dietary supplements:

• All CAM products available in the U.S. - particularly dietary supplements - should be safe and held to appropriate standards of quality and consistency.
• All provisions contained in the Dietary Supplement Health and Education Act of 1994 (DSHEA) should be "fully implemented, funded, enforced, and evaluated." To accomplish this, the Commission recommends providing additional resources to the Food and Drug Administration, and having Congress periodically review DSHEA and take corrective action when necessary.
• The Federal Trade Commission should receive funding to ensure that the advertising of dietary supplements and other CAM products is truthful and not misleading to the public.

Education and Training

• Conventional health professional schools should develop "core curricula of knowledge about CAM" so that they can discuss these treatments with patients and help them make informed choices about the type of care patients receive. Likewise, CAM training programs need to develop core curricula that discuss "fundamental elements of biomedical science and conventional health care" as they relate to complementary and alternative medicine.
• CAM education and training should continue beyond the qualifying degree level. Before establishing new programs or expanding current ones, however, the feasibility, duration and impact of existing programs need to be evaluated.
• The federal government should make accurate, easily accessible information on CAM available to the public. To do this, the Commission recommends the establishment of a task force comprised of consumers, practitioners and scientists to "facilitate the development and dissemination of CAM information · and to eliminate existing gaps in CAM information."
• Because it is difficult to determine the quality and accuracy of CAM information on the Internet, the Commission recommends that HHS establish a voluntary standards board that would review health-related websites, along with a public education campaign and other actions that would protect consumer privacy.
• To ensure consumer safety, the Commission recommends making practitioners' qualifications readily available. State regulations, requirements and disciplinary actions regarding CAM and CAM practitioners should also be made available to the public.

Access and Delivery

• Several barriers currently exist to prohibit consumers from having easy access to CAM. The Commission recommends that HHS evaluate these barriers and design strategies to remove them. HHS is also charged with examining existing states' legislation to see how those laws impact access to CAM therapies.
• HHS should create a policy advisory committee that will address issues related to access to CAM practitioners and provide guidance on regulatory issues.
• Nationally recognized accrediting bodies should evaluate how health care organizations (under their oversight) are using CAM practices and develop guidelines for the safe and appropriate use of CAM practitioners in certain conditions.
• HHS and other federal departments should identify health care models that already incorporate CAM, evaluate them, and support the models that are most successful, especially for use in "special and vulnerable" populations such as patients who are chronically or terminally ill. It is also recommended that HHS develop demonstration projects that integrate CAM as part of the health care programs offered in hospices and community health centers.

Coverage and Reimbursement

• The Secretary of Health and Human Services should create a joint public/private task force to identify which health issues related to CAM should be studied first.
• Federal agencies, states and private organizations should increase funding for health services research related to CAM, including treatment outcomes; coverage and access; integration with conventional forms of care; effective models of delivery; and cost-effectiveness.
• A national coding system supporting standardized CAM data should be implemented. The creation of such a system would accelerate the collection of data from CAM research and support compliance with the requirements of the soon-to-be-implemented Health Insurance Portability and Accountability Act (HIPAA).
• The National Center for Complementary and Alternative Medicine's clearinghouse should provide information on health services research, demonstrations and evaluations of CAM services and products.
• Health insurers and managed care organizations should modify their benefit programs to offer purchasers the option of plans that include CAM treatments, and should make use of CAM experts in the development or modification of these programs.
• Public purchasers of health benefit packages such as the Centers for Medicare and Medicaid Sciences and the Department of Defense should include CAM practitioners and experts on advisory bodies that consider CAM benefits and other health-related issues.

Wellness and Health Promotion

• The federal government, along with public and private organizations, should evaluate CAM practices to determine their potential in promoting health and wellness. Demonstration programs should be funded for those therapies shown to have merit, and national health surveys should include questions on the extent and use of CAM products and practices.
• Federal, public and private agencies should evaluate safe and effective forms of CAM as they pertain to improving nutrition, promoting exercise and teaching stress management to children. Demonstration programs should be funded for therapies shown to have value. In addition, all federal agencies that develop school health guidelines should evaluate the potential use of CAM to those guidelines. CAM treatments shown to be beneficial should be included in the guidelines.
• HHS and the Department of Labor should examine the role of CAM in workplace wellness and prevention activities.
• The federal government and private health organizations should evaluate CAM procedures currently used for wellness and health to determine their effectiveness in managing chronic diseases. Funding should be provided for demonstration projects in the Centers for Medicare and Medicaid Services, the Departments of Defense and Veterans Affairs, the Health Resources and Services Administration, and other agencies.

Government Coordination

• An office should be created, either by the President, Secretary of Health and Human Services or Congress, that will coordinate all federal CAM activities and facilitate the integration of all CAM practices found to be safe and effective into the national health care system. The office should be established under the auspices of HHS and charter an advisory council, whose members include CAM and conventional practitioners.
• The responsibilities of the office will include, but not be limited to: acting as a liaison with conventional health care and CAM professionals, organizations and institutions; planning and facilitating meetings, workshops and advisory groups; acting as a central point of contact regarding CAM for the public, health care providers and the media; implementing the Commission's recommendations and actions; and exploring additional topics.

"There's a lot that needs to be digested · before taking the next step."

Although the Commission's recommendations are non-binding, and are intended to serve merely as a framework for future government studies, they have stirred controversy among both critics and advocates of complementary and alternative medicine. Some of this controversy may be attributed to the deliberately non-specific nature of the report, which lumps both proven and unproven forms of CAM into one category. For instance, while the group recommends that insurers and managed care organizations "should offer purchasers the option of health benefit plans that incorporate coverage of safe and effective CAM interventions," the report fails to mention which forms of CAM they consider safe and effective. In fact, in the report's introduction, the Commission's members admit that "most CAM interventions have not yet been scientifically studied and found to be safe and effective."

Furthermore, not every member of the Commission agreed with the final report's conclusions. In a separate statement, two panelists criticized the report for being overly generic and vague.

"While many of the Commission's recommendations will help maximize the benefits of proven safe and effective approaches, practices and products, they do not appropriately acknowledge the limitations of unproven and unvalidated CAM interventions or adequately address the minimization of risk," the panelists wrote.

The Commission acknowledged the other panelists' criticism in its introduction. "The report does its best to distinguish in its recommendations between those proven safe and effective and those that are not. But the Commission recognizes that this distinction may not always be clear," they wrote.

It is also unclear as to how much credence will be given to the Commission's work by the Bush administration, given that the organization providing the report was created by former President Clinton. In an interview with Reuters Health, Bill Hall, a spokesperson for Health and Human Services, said, "There's a lot that needs to be digested first before taking the next step of saying where we're going to go."² Hall added that the department would consider the Commission's recommendations, but that it was "premature" to say what might happen in the future.

Others have voiced their support for the group's efforts, including Senator Tom Harkin (D-Iowa), a long-time proponent of alternative therapies.

"I'm hopeful the commission's recommendations will help move toward the day that Americans can get the best of both traditional medicine and complementary medicine," Senator Harkin told the Washington Post. "Public policy has not kept up with consumers or the science in this area. People are spending record sums out of their own pockets for complementary health care, and they have a right to expect good and reliable information and continued access."³

Exactly what impact the final report of the White House CAM Policy Commission will have on complementary and alternative medicine in the United States remains to be seen. Nevertheless, in many ways, the "final" report represents an important first step in the recognition of complementary and alternative medicine. With its mantras of education, information and research as the keys to making informed, intelligent decisions about health care, the Commission's report sets the foundation upon which further actions by the federal government and private health care organizations can be built, and is sure to spark debate among practitioners across the full spectrum of the health care profession for years to come.

References

1. HHS quietly releases White House commission report on alternative medicine. Reuters, March 25, 2002. Available at www.reutershealth.com.
2. Ault A. U.S. alternative medicine report spurs controversy. Reuters, March 25, 2002. Available at www.reutershealth.com.
3. Packer-Tursman J. Alternative health panel under attack. Washington Post March 19, 2002; p. HE01.

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Editor's note: A complete copy of the White House CAM Commission's final report is available for viewing and printing via the Internet. Interested parties can access the report at http://whccamp.hhs.gov.