By Craig Mehrmann, NMSA President
On Monday, May 22, representatives from the Naturopathic Medical Student Association (NMSA) will be joining forces with the American Association of Naturopathic Physicians (AANP) on Capitol Hill to urge congressional support for a Medicare pilot project. The purpose of the project is to demonstrate the value of removing health care access barriers to naturopathic medical providers for nearly 54 million citizens currently receiving Medicare. The quality of medical care in the United States is on average inferior to that of countries which have remarkably lower healthcare costs and expenditures, with 40% of Americans (130+ million) affected by chronic disease.(1-2) No other developed country even comes close to the United States in annual spending on healthcare.(3) This, despite the fact that over 35 million American citizens have no coverage, and millions more have inadequate protection.(3,4) Perhaps the most revealing statistics of all, with regard to the state of the U.S. healthcare system, would be that treating chronic disease accounts for 86% of U.S. healthcare spending, while chronic disease rates continue to rise.(5,6) The United States healthcare system is clearly in need of significant reform. Including naturopathic physicians in Medicare would be a financially viable step forward in addressing the healthcare crisis by increasing access to preventative and restorative primary care services in a climate of shortage, while providing gainful employment opportunities for a profession exceptionally poised to help remedy the chronic disease epidemic currently facing the U.S. healthcare system.
In the United States, chronic diseases account for 7 out of every 10 deaths.(5) Heart disease, cancer and stroke account for more than half of all deaths each year, and over 70% of American adults are overweight or obese.(5,7) On a global basis, it has been projected that by 2020 chronic diseases will account for almost three-quarters of all deaths, and that 71% of deaths due to ischemic heart disease, 75% of deaths due to stroke, and 70% of deaths due to diabetes will occur in developing countries.(8,9) The number of people with diabetes in the developing world will increase more than 2.5-fold, from 84 million in 1995 to 228 million in 2025.(8,10) Worldwide, 60% of the burden of chronic diseases will occur in developing countries.(8)
Chronic diseases are largely preventable. Currently available scientific evidence provides a strong basis to justify the efficacy of psycho-emotional, environmental, diet and lifestyle modifications in treating chronic diseases.(8) Primary prevention is considered the most cost-effective, affordable and sustainable course of action to address the chronic disease epidemic in the United States and worldwide.(8) By including naturopathic physicians in Medicare, we would take a meaningful step forward in reducing chronic disease burden in the United States, while serving as an example to other countries also faced with the global chronic disease epidemic.
Several factors have constrained progress in the prevention of chronic diseases: underestimation of the effectiveness of worthwhile interventions, the belief that there is a long delay in achieving measurable impact, commercial pressures, institutional inertia and misallocation of resources.(8) These factors need to be taken seriously and decisively addressed. In order to remedy this complex issue, the United States government must support the ongoing efforts of non-conventional healthcare professions that focus primarily on treating diseases where meaningful outcomes can only be attained through psycho-emotional, environmental, diet and lifestyle modifications. Naturopathic doctors are the only primary care physicians trained extensively in counseling, nutrition, exercise prescriptions, stress management, and appropriate botanical and pharmaceutical intervention needed to specifically address the lifestyle modification, prevention, early intervention, and long term restorative healing processes needed by those affected by chronic disease.
Moreover, supporting increased access to naturopathic physicians is financially viable. Since 1996, Washington state law has required private health insurance to cover licensed complementary and alternative medical (CAM) providers. In the state of Washington, 67.7% of patients who receive primary care from a naturopathic physician do not receive concurrent primary care from a medical doctor (MD) or doctor of osteopathic medicine (DO).(11) Therefore, in states that license naturopathic doctors (NDs), and provide a scope of practice that fulfills their level of training, naturopathic primary care is not an “add-on” health care service. Furthermore, visits to naturopathic physicians cost about half as much as visits to conventional providers, and the annual health care expenditures for insured integrative medicine users in Washington State were $356 less than that of non-integrative medicine users.(12,13)
A 2011 survey conducted by the Innovative Research Group in Ontario found that 28% of patients who saw NDs reported significantly or noticeably reduced use of prescription drugs, 19% reported reduced visits to the hospital, 18% reported reduced use of expensive medical specialists, and 57% believed naturopathic medicine is leading to better health outcomes for those who use it.(14) Moreover, the Vermont Auto Dealer’s Association (VADA) Wellness Program administered by naturopathic doctors saved nearly $1.5 million in medical costs ($1,800 per employee) in the first year that naturopathic physicians were made available to their members, producing a return on investment of $21 for every $1 spent on direct and indirect costs, with only 0.2% increase in per member claims costs compared to the national average of 7% in 2005. Under this program, every VADA-identified health risk showed improvement over two years.(15)
The rapidly increasing primary care shortage in the United States provides another key element that must be taken into consideration by U.S. Congress in their decision to include NDs in Medicare. The American Association of Medical Colleges (AAMC) anticipates a shortage of 90,000 primary care physicians in the United States by 2025.(16,17) Licensed NDs that have graduated from an institution recognized by the Council on Naturopathic Medical Education (CNME) are trained as primary care physicians in accredited, four-year, residential graduate medical colleges and pass two extensive licensing examinations (NPLEX I and II). Licensed naturopathic physicians must fulfill state-mandated continuing education requirements annually, and have a specific scope of practice defined by the law in their state. In several states, NDs can obtain DEA numbers, have the authority to prescribe any pharmaceutical needed in a primary care setting, and use pharmaceuticals alongside botanical medications. They can also conduct minor surgical procedures, as well as order, dispense and administer topical and intravenous preparations, medical equipment and mechanical devices, all labs and diagnostic procedures, antibiotics and vaccines, and homeopathic preparations.
Accredited naturopathic medical schools provide rigorous medical training in a primary care model that effectively treats the “Achilles heel” of conventional medicine – preventable chronic diseases. While training in naturopathic medical programs is comparable to the level of rigor of conventional medical programs, it is also comparable in cost, with the average total tuition of naturopathic medical school amounting to $140,000-170,000.(18) However, ND graduates face significant financial strains far exceeding their MD/DO counterparts due to limited access to scholarship opportunities, loan repayment programs, and gainful employment opportunities in the mainstream healthcare system.
Access to post-graduate residency and training programs is also limited for ND graduates. Total federal graduate medical education (GME) funding for MDs and DOs exceeds $15 billion per year. The single largest explicit contributor to GME is Medicare ($9.7 billion), followed by Medicaid ($3.9 billion) and the Veterans Health Association (VHA) ($1.4 billion).(19) In contrast, ND residency and training programs are privately funded, causing significant barriers to professional development. In conventional medical school, students typically undergo two years of training in basic sciences and two years of clinical rotations, and commit to a specialty during residency training. Naturopathic medical students, however, focus on training in primary care throughout their schooling, and can choose to participate in a privately funded residency to deepen their training in a particular area of specialization, and to provide a sustainable transition into the workforce. However, due to funding limitations, ND residency salaries average ~$20,000 less than MD/DO residencies, and there are currently not enough ND residencies available for all ND students, limiting access to post-graduate training for those who may wish to pursue it. It is important to highlight that the ND profession is significantly smaller than either the MD or DO professions, and would require only a small fraction of GME funding in comparison to provide adequate support.
Naturopathic doctors have taken a road less traveled in order to provide a much needed service to their patients. Their road is challenging in every sense of the word: their training is equally rigorous and equally expensive compared to their MD/DO counterparts, and they must navigate significant barriers to loan repayment, gainful employment, and reimbursement. Moreover, their patients, particularly seniors and disabled who depend on Medicare for insurance, must navigate significant access barriers to naturopathic doctors. According to a 2014 survey, 55% of seniors would consider visiting an ND, 1 in 4 of those seniors would pay out of pocket for naturopathic care, and almost 100% would visit an ND if their services were covered by Medicare.(20) It is high time that naturopathic physicians are reasonably supported in providing their services through a healthcare system in dire need of their expertise – treating pervasive chronic diseases that are only amenable to treatments based on preventative, restorative, and lifestyle factors – with a salary that reflects their level of training and cost of tuition.
Please contact your national association to learn more about our efforts to increase patient access to licensed naturopathic doctors:
United States: http://www.naturopathic.org/
Craig Mehrmann is a third year ND, MSOM student at the National College of Natural Medicine, and serves as 2015-2016 president of the Naturopathic Medical Student Association (NMSA).
1. Centers for Disease Control and Prevention. The Power of Prevention. (2009) Accessed at http://www.cdc.gov/chronicdisease/pdf/2009-Power-of-Prevention.pdf
2. Centers for Disease Control and Prevention. http://www.cdc.gov/chronicdisease/
4. Centers for Disease Control and Prevention. Accessed at http://www.cdc.gov/nchs/fastats/health-insurance.htm
5. Centers for Disease Control and Prevention. Accessed at http://www.cdc.gov/chronicdisease/
7. Centeres for Disease Control and Prevention. Accessed at http://www.cdc.gov/nchs/fastats/obesity-overweight.htm
8. World Health Organization. The Global Burden of Chronic Disease. Accessed at http://www.who.int/nutrition/topics/2_background/en/
9. The world health report 1998. Life in the 21st century: a vision for all. Geneva, World Health Organization, 1998.
10. Aboderin I et al. Life course perspectives on coronary heart disease, stroke and diabetes: key issues and implications for policy and research. Geneva, World Health Organization, 2001 (document WHO/NMH/NPH/01.4).
11. Cherkin DC, Deyo RA, Sherman KJ et al. Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. J Am Board Fam Pract. 2002;15:463-472.
14. Attitudes Toward Naturopathic Medicine. Innovative Research Group. September 1, 2011. www.innovativeresearch.ca,
15. Vermont Automobile Dealer’s Association and Green Mountain Wellness Solutions http://www.greenmountainwellness.com/ ; http://www.vermontada.org/wellness.asp
16. AAMC. Accessed at https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf
18. AANMC. Accessed at https://aanmc.org/resources/comparing-nd-md-curricula/
19. Eden, Jill, Donald Berwick, and Gail Wilensky. “Graduate medical education that meets the nation’s health needs.” Washington, DC: Institute of Medicine of the National Academies (2014).
20. AANP. Accessed at http://www.naturopathic.org/content.asp?admin=Y&contentid=807