Alfie Vente, RMT, D. Ac (Cand.)
An interdisciplinary model of care is an ideal situation for practitioners and patients. Many in healthcare believe that this is the model that must be utilized to maximize patient care. According to recent research, the lack of communication has resulted in 70 percent of the adverse affects of a patient.1
Unfortunately, there are definitely a number of realistic stumbling blocks to achieving this goal of an interdisciplinary setting. I have had the fortunate experience of working in an Ontario hospital as a massage therapy clinic supervisor and I am currently working in two different clinics that have two different approaches. One is multidisciplinary and the other interdisciplinary.
There are struggles and advantages of these two different settings. What I would like to discuss are the stumbling blocks of an interdisciplinary model. These hurdles extend out to acupuncturists and TCM practitioners. At times, multidisciplinary and interdisciplinary modes will be compared.
In Ontario and in Canada in general we have a two-tiered system of healthcare. We have a social system and a private system. To some it may seem unfair to have two different systems. There are two reasons for this, among others. The first reason is that at times both systems lack harmony, in terms of communication from practitioner to practitioner (usually MD to complementary therapist or vice-a-versa). This is a frustrating situation for a patient who seeks proper treatment and wants those involved with their care to communicate about progress, treatment, potential stumbling blocks etc. Also, many healthcare practitioners lack the understanding of what other disciplines may do and their function within the healthcare system.
There are many misunderstandings as to what each does. Two good examples of this are: "acupuncture only treats pain" and "massage is only for relaxation." Of course those in the field and who have had treatments from these two disciplines understand that these two forms of healthcare do much more than that.
Complementary therapies are generally part of the private system in Ontario. This includes massage therapy, chiropractic, naturopathy, acupuncture and TCM as well as homeopathy. We find these modes of therapies in privatized clinics. What may seem disconcerting is that it was found that 26 percent of those that used these therapies fell in the highest income group, while only 13 percent of those in the lowest income group had used these therapies.2 It is rare to actually find any of these types of practitioners being salaried employees at a hospitals. Generally hospitals in Ontario fall into the social medicine system.
So, how does the interdisciplinary approach relate to acupuncture in a wellness clinic?
First off, we have to differentiate between multidisciplinary and interdisciplinary. What are the key differences? In a multidisciplinary setting each practitioner is a "specialist" in a particular discipline such as massage or chiropractic. In this setting the healthcare provider works with the patient according to his/her specialty and assesses and treats them according to the particular specialty and its philosophy. They are generally an "island" unto themselves. The practitioner may refer out to another therapist. In this setting you will potentially see each provider having separate files for the patient. To see 3, 4 or 5 different files for one patient is common in this setting.
According to author Rebecca Jessup, "Interdisciplinary team approaches, as the word itself suggests, integrate separate discipline approaches into a single consultation."3 Basically the patient would have the healthcare team performing the health history, assessment/diagnosis and treatment plan altogether in one appointment. The team would bring in their specialty together and gather the information concurrently to form an integrated plan for treatment. The patient has a strong say in their treatment plans and both patient and practitioners have an "even" understanding of the state of all that is involved.
In this setting, there would be one file where all the particular providers would write their findings. This system allows other providers treating that particular patient to view what others are doing or have done.
There are significant advantages for an acupuncturist/TCM practitioner with this system. In Ontario, acupuncture is a relative newcomer to be regulated in the province. It is critical that the acupuncturist communicate and educate other health care providers of what acupuncture could treat. In an interdisciplinary setting, the acupuncturist will be able to communicate relatively freely with other providers and share any findings that may help in a patient's treatment. If you were to compare this to a multidisciplinary setting, each practitioner is seemingly more concerned as to what their individual therapy can provide.
One of the goals for the acupuncturist in this setting is to gain the trust of other practitioners. This will happen over time with constant communication. More trust will lead to further referrals allowing the acupuncturist to flourish. Along with this, the patient will view the acupuncturist/TCM practitioner as an equal profession relative to the others in the consulting group.
The positive reasoning for the use of interdisciplinary approach has been discussed, but what are the stumbling blocks to a full interdisciplinary approach?
The first question that must be asked is, is it practical? It is an ideal situation but is it more cumbersome for the patient and therapists? In a wellness clinic situation you will generally have practitioners such as massage therapists, acupuncturists/TCM practitioners, naturopaths, homeopaths, chiropractors and potentially physiotherapists all working under one roof. You may also have medical personnel such as family doctors or sports medicine doctors.
What has been found in the interdisciplinary clinic I practice in, is that there is a chance for redundancy. In particular the physiotherapist and chiropractor. In this situation the patient first is assessed by the chiropractor and then the physiotherapist in separate appointments, usually back to back on the same day. Eventually what happens is both practitioners get together and formulate a treatment plan. Almost, a high-breed between multidisciplinary and interdisciplinary.
In Ontario there is much cross-over between chiropractors, physiotherapists and massage therapists in terms of their scope of practice.
In the above situation it would be more ideal for the patient to be assessed by the entire group of practitioners in one appointment as to reduce the redundancy. This is probably the best way to deal with patients. As you will see later, this may be ideal from one dimension, but from a business or therapist perspective, working in a private setting, it may be least ideal.
Timing can be an issue with the private interdisciplinary model. What generally happens in a private model is that therapists may have other appointments and it may be very difficult to bring them together for one particular appointment to meet the patient, diagnose/assess, discuss the treatment plan etc. This becomes even more difficult when the clinic becomes busier if they are an upstart clinic. Eventually what may happen is that the clinics' philosophy eventually goes back from interdisciplinary to multidisciplinary to accommodate timing issues.
The private wellness clinics in Ontario are driven by the insurance companies. You could see this most evident when massage therapists are generally the busiest approximately 6-8 weeks before the end of December. The reason for this is that these individuals understand that their work benefits end at the end of the year and start up again in the new year. Knowing this, most patients in the know decide to "use up" their benefits before year end.
In Ontario, regulated health professionals have a registration number that is put on receipts so that patients can send these receipts to their insurer for reimbursement.
In the case of a true interdisciplinary setting, where the practitioners initially meet with the patient together, it would be very difficult to bill for multiple practitioners when the actual assessment has been performed. When you have for example a naturopath, who can also do acupuncture/TCM assessments and an actual acupuncturist/TCM practitioner or a physiotherapist and a chiropractor who have tremendous cross-over of scope, it will be difficult to bill for separate appointments and to justify the separate billings to the insurance company when the assessment is done as a team in one appointment.
So, how do you break down the actual cost of the "team" assessment? In Ontario, most private centered clinicians work under a percentage split or on a per patient basis.
When the actual team interdisciplinary assessment process occurs, how will the clinic bill?
Will it be a "one shot" fee? And, if so how will that be divided amongst all the therapists involved with the assessment/initial meeting? Will it be 3 or 4 or 5 different receipts billed as one appointment? or will their be a breakdown of costs for the patient, i.e. $90.00 for chiropractic assessment, $90.00 for physiotherapist assessment, $110.00 for naturopath etc?
One of the issues that will come up for this is the actual "out-of-pocket" expense for the patient. It would be a first time expense that would cost $500 or more for the initial visit. This is an estimate based on current fees of healthcare providers.
This initial cost would scare off many would-be patients of a clinic. Their insurance may reimburse them, but it is a seemingly steep price for the first initial appointment. One solution for this may be to direct bill an insurer for the first appointment.
Realistically from a business perspective, how does one recoup if a patient misses their appointment or cancels within an allowable time frame? If a person fails to show for an appointment the clinicians and clinic could lose a large sum of revenue.
The clinic would be in a "triple whammy" situation whereby they would lose on the missed appointment, plus potentially lose that ability to book another individual who could have shown up.
Finally, that person seeking that particular appointment may decide to go to another clinic on the basis of the inability to be booked in.
In a multidisciplinary setting you may have one particular therapist who loses an appointment because of a cancellation, but it is just one therapist as opposed to multiple therapists waiting on a particular patient to show up.
In socialized medicine such as that in Ontario hospitals, the interdisciplinary approach works better.
The reason for this is that the providers are paid, generally on a per hour basis or salaried unlike the example of privatized wellness clinics.
Doctors, nurses, occupational therapists, physiotherapists and other health care practitioners can meet with a particular patient together without having the hurdles that have been listed above.
They get paid on an hourly basis and have less fear of losing income because of a patient failing to show.
How the initial assessment will be billed is a non-worry or how their "piece of the pie" will be broken up for them is also less of a concern.
Health care practitioners may have decided to go a certain path for noble reasons, but if that particular clinic or career path they have chosen fails to generate a decent living, that individual may decide to find another clinic or a career altogether to fit this need.
Realistically a private clinic must find a balance of generating money and providing outstanding care for a particular patient.
In a perfect world the perfect wellness clinic would be generating substantial amounts of revenue and be profitable, clinicians would have tremendous satisfaction in what they do from both a "healers" perspective and from generating a good income, the patients would be satisfied with their care and the clinic is well integrated with the social part of the healthcare system.
The interdisciplinary approach is the way to go.
Acupuncturists/TCM practitioners should find practices that will get them thoroughly involved with this model.
The acupuncturist/TCM practitioners should also be part of solving these issues that potentially could be walls to a successful clinic or career.
The more aggressive we are in our participation particularly in our infancy as regulated health professionals, will lead to further benefits to the acupuncture/TCM industry in the future.
References
- Interdisciplinary collaboration for healthcare professionals, Fewster-Thuente L, Velsor-Friedrich B.
- Park, USE OF ALTERNATIVE HEALTH CARE, Health Reports, Vol. 16, No. 2, March 2005 Statistics Canada
- Interdisciplinary versus multidisciplinary care teams: do we understand the difference?, Australian Health Review / August, 2007
