- Email: [email protected]
A survey of patients’ out-of-pocket payments for complementary and alternative medicine therapies
Complementary Therapies in Medicine (2004) 12, 48—50
A survey of patients’ out-of-pocket payments for complementary and alternative medicine therapies I. Peytremann Bridevaux a,b,* a
HSR&D VA Puget Sound Health Care System, Seattle, WA, USA Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, WA, USA
b
Summary Objective: Investigate the out-of-pocket payments for complementary and alternative therapies. Design: Cross-sectional study using the 1996 Medical Expenditure Panel Survey. Setting: Fourteen thousand and twenty-six US adults aged ≥25 years from 10,597 answering households. Respondents to the survey were only included in this analysis if they used a single CAM therapy which was not covered by insurance. Main outcome measure: Reported out-of-pocket payments. Results: Out of 836 users of alternative therapies, 577 used only a single therapy. Massage therapy (23.7%), spiritual healing (16.6%) and herbal therapy (14.7%) were the most frequently single used therapies. The out-of-pocket payments per visit for providers was on average $49 for nutritional advice, $44 for acupuncture, $33 for massage, $23 for herbal therapies, and $9 for spiritual healing. Conclusions: These are the first estimates of the out-of-pocket payments for specific complementary and alternative therapies. They can help understand the importance people place on these therapies. © 2003 Elsevier Ltd. All rights reserved.
Introduction Several national population-based surveys have shown that a substantial part of the population uses complementary and alternative medicine (CAM) therapies.1—9 Assessing what individuals pay for CAM therapies reflects the importance they place on these therapies. Two national surveys looked at global out-of-pocket payments for CAM therapies2,9 but to date, nothing has been published on out-of-pocket payments for specific CAM therapies. ∗
Tel.: +41-22-346-14-76; fax: +41-22-346-14-76. E-mail address: [email protected] (I.P. Bridevaux).
The objective of this study was to investigate the amount of out-of-pocket payments that US non-institutionalized civilians made for specific CAM therapies, using the Medical Expenditure Panel Survey data from 1996.
Methods The Medical Expenditure Panel Survey (MEPS) is a nationally representative survey of the US non-institutionalized civilian population. The data used in this study came from the 1996 MEPS Household Component, which comprised 22,601 individuals from 10,597 answering households. This
0965-2299/$ – see front matter © 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0965-2299(03)00127-4
A survey of patients’ out-of-pocket payments for complementary and alternative medicine therapies cross-sectional study was restricted to adults aged 25 years or older. MEPS participants were asked whether they had consulted a provider of the following types of complementary and alternative therapies: acupuncture, nutritional advice, massage, herbal, biofeedback, meditation, homeopathy, spiritual healing, hypnosis, traditional medicine or other, for health reasons during the previous calendar year. If the response was ‘‘yes’’, the participant was asked to specify which of the treatments had been received. Use of multiple CAM therapies was possible. In MEPS, chiropractic was not included in the questions relating to CAM therapies but was treated as a form of conventional medicine. Therefore, as it could not be evaluated, it was not included in the analysis. Individuals who used only one CAM therapy in 1996 were then selected. Basic demographics, types of provider-based CAM therapies used, estimated number of visits to CAM providers and estimated amount of money spent for CAM were analyzed. The out-of-pocket calculations included only the following five CAM therapies used without other types: massage therapy, spiritual healing, herbal therapy, nutritional advice and acupuncture. The others were not considered because too few people were included in each of them (n < 15) and as the ‘‘other’’ category included many different types of CAM therapies. Reported out-of-pocket payments per visit, for each specific CAM therapy and for respondents whose CAM therapies were not covered by insurance, were constructed by dividing the amount paid for CAM providers by the number of visits to CAM providers, including only people who had no insurance or no insurance coverage for CAM. Population weights were applied to provide generalization to the US non-institutionalized civilian population. All statistical analyses were conducted using STATA 7.0.
49
Results Overall, 14,026 adults 25 years or older were included in the analysis. CAM was used at least once during 1996 by 6.1% (n = 836) of the sample, representing an estimated 11.2 million US non-institutionalized civilians. Of the 10 CAM therapies listed, the three most commonly used therapies were massage therapy (35%), herbal therapy (31%) and spiritual healing (25%). Out of the 836 users of CAM, 577 (69%) used only a single CAM therapy. Massage therapy (23.7%), spiritual healing (16.6%) and herbal therapy (14.7%) were also the three most frequently used CAM therapies among users of a single CAM therapy. Table 1 shows the mean amount of reported out-of-pocket money per visit paid for the five specific CAM therapies. The highest average amount of out-of-pocket money was paid for nutritional advice providers. Acupuncture, massage and herbal therapies providers came next, and last were spiritual healing providers with $9 paid per visit, on average.
Discussion The reported mean out-of-pocket payments per visit for CAM providers was $49 for nutritional advice, $44 for acupuncture, $33 for massage, $23 for herbal therapies, and $9 for spiritual healing. Reasons cited in the literature, for the trend toward the use of alternative therapies include a preference for a more holistic, integrative form of medicine, and a desire to use less technical and costly as well as more natural treatments, perceived as having fewer side effects.10—15 Dissatisfaction with conventional care, thought to be one reason for seeking alternative care, has been shown not to be a predictor of CAM use.4,16 Even
Table 1 Average reported out-of-pocketa money paid for CAM therapies.b Single used CAM therapies
Out-of-pocket money/visit paid for CAM providers: mean (S.D.), minimum—maximum
Nutritional advice (n = 83) Acupuncture (n = 33) Massage (n = 169) Herbal (n = 99) Spiritual healing (n = 125)
$49 (75), 0—450 $44 (38), 0—133 $33 (22), 0—140 $23 (49), 0—240 $9 (91), 0—1000
a
Out-of-pocket expenditure (rounded to the closest integer) = mean amount paid/mean number of visits, for a specific CAM therapy. b Respondents only included if their use of complementary and alternative therapy was not covered by insurance.
50 though spiritual healing is the second most used single therapy patients did not pay a great deal for it, although some patients paid up to $1000 for it. Herbal therapies and nutritional advice are two of the most frequently used and paid for CAM therapies. Because the majority of patients do not discuss their use of alternative therapies with their conventional care provider1,2,5 and as complications might occur after the use of herbs17 and nutritional supplements18 it seems necessary to be aware of the high use of these two therapies. The results of this study have two main limitations. First, there is no consensus on which therapies to include in CAM, defined many years ago as ‘‘medical interventions not taught widely at US medical schools or not generally available at US hospitals’’.1 As the MEPS list does not include chiropractic care as part of CAM, one widely used CAM therapy was not considered in our results. Second, these results excluded individuals using multiple CAM therapies. Therefore, they probably underestimate the reported amount paid out-of-pocket for CAM therapies, and generalization to all CAM users is not possible. CAM therapies have a substantial presence in industrialized countries, and more and more calls for the integration of CAM into the health care system rather than for a separation from conventional care are appearing in the health care literature.19,20 CAM efficacy studies, as well as studies based on costs and utilization data are necessary to help integrate the right care in the health care system, whether it is conventional or not. In this context, and because these are the first estimates of the average reported out-of-pocket payments people paid for specific CAM therapies, representing the importance people place on these therapies, the results of this study should be of value for health and public health professionals.
I.P. Bridevaux
3. 4. 5. 6. 7. 8.
9. 10. 11. 12. 13. 14. 15.
16.
17. 18.
References 1. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med 1993;328:246—52. 2. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990—1997.
19. 20.
Results of a follow-up national survey. J Am Med Assoc 1998;280:1569—75. Paramore LC. Use of alternative therapies: estimates from the 1994 Robert Wood Johnson Foundation National Access to Care survey. J Pain Symptom Manage 1997;13:83—9. Astin JA. Why patients use alternative medicine. Results of a national survey. J Am Med Assoc 1998;279:1548—53. Druss BG, Rosenheck RA. Association between use of conventional therapies and conventional medical services. J Am Med Assoc 1999;282:651—6. Wolsko P, Ware L, Kutner J, et al. Alternative/ complementary medicine: wider usage than generally appreciated. J Altern Complement Med 2000;6:321—6. Bausell RB, Lee WL, Berman BM. Demographic and health-related correlates of visits to complementary and alternative medical providers. Med Care 2001;39:190—6. Ni H, Simile C, Hardy AM. Utilization of complementary and alternative medicine by United States adults. Results from the 1999 National Health Interview Survey. Med Care 2002;40:353—8. Thomas KJ, Nicholl JP, Coleman P. Use and expenditure on complementary medicine in England: a population based survey. Complement Ther Med 2001;9:2—11. Furnham A, Bhagrath R. A comparison of health beliefs and behaviours of clients of orthodox and complementary medicine. Br J Clin Psychiatry 1993;32:237—46. Furnham A, Smith C. Choosing alternative medicine: a comparison of the beliefs of patients visiting a general practitioner and a homeopath. Soc Sci Med 1998;26:685—9. Furnham A, Forey J. The attitudes, behaviours and beliefs of patients of conventional vs. complementary (alternative) medicine. J Clin Psychol 1994;50:458—69. Kaptchuk TJ, Eisenberg DM. The persuasive appeal of alternative medicine. Ann Intern Med 1998;129:1061—5. Vincent C, Furnham A. Why do patients turn to complementary medicine? An empirical study. Br J Clin Psychol 1996;35:37—48. Vincent C, Furnham A, Willsmore M. The perceived efficacy of complementary and orthodox medicine in complementary and general practice patients. Health Educ Res 1995;10:395—405. Eisenberg DM, Kessler RC, Van Rompay MI, et al. Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey. Ann Intern Med 2001;135:344—51. Ernst E. Harmless herbs? A review of the recent literature. Am J Med 1998;104:170—8. McGuire JK, Kulkarni MS, Baden HP. Fatal hypermagnesemia in a child treated with megavitamin/megamineral therapy. Pediatrics 2000;105:E18. Dalen EJ. ‘‘Conventional’’ and ‘‘unconventional’’ medicine. Can they be integrated? Arch Intern Med 1998;158:2179—81. Davidoff F. Weighting the alternatives: lessons from the paradoxes of alternative medicine. Ann Intern Med 1998;129:1068—70.
A survey of patients’ out-of-pocket payments for complementary and alternative medicine therapies I. Peytremann Bridevaux a,b,* a
HSR&D VA Puget Sound Health Care System, Seattle, WA, USA Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, WA, USA
b
Summary Objective: Investigate the out-of-pocket payments for complementary and alternative therapies. Design: Cross-sectional study using the 1996 Medical Expenditure Panel Survey. Setting: Fourteen thousand and twenty-six US adults aged ≥25 years from 10,597 answering households. Respondents to the survey were only included in this analysis if they used a single CAM therapy which was not covered by insurance. Main outcome measure: Reported out-of-pocket payments. Results: Out of 836 users of alternative therapies, 577 used only a single therapy. Massage therapy (23.7%), spiritual healing (16.6%) and herbal therapy (14.7%) were the most frequently single used therapies. The out-of-pocket payments per visit for providers was on average $49 for nutritional advice, $44 for acupuncture, $33 for massage, $23 for herbal therapies, and $9 for spiritual healing. Conclusions: These are the first estimates of the out-of-pocket payments for specific complementary and alternative therapies. They can help understand the importance people place on these therapies. © 2003 Elsevier Ltd. All rights reserved.
Introduction Several national population-based surveys have shown that a substantial part of the population uses complementary and alternative medicine (CAM) therapies.1—9 Assessing what individuals pay for CAM therapies reflects the importance they place on these therapies. Two national surveys looked at global out-of-pocket payments for CAM therapies2,9 but to date, nothing has been published on out-of-pocket payments for specific CAM therapies. ∗
Tel.: +41-22-346-14-76; fax: +41-22-346-14-76. E-mail address: [email protected] (I.P. Bridevaux).
The objective of this study was to investigate the amount of out-of-pocket payments that US non-institutionalized civilians made for specific CAM therapies, using the Medical Expenditure Panel Survey data from 1996.
Methods The Medical Expenditure Panel Survey (MEPS) is a nationally representative survey of the US non-institutionalized civilian population. The data used in this study came from the 1996 MEPS Household Component, which comprised 22,601 individuals from 10,597 answering households. This
0965-2299/$ – see front matter © 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0965-2299(03)00127-4
A survey of patients’ out-of-pocket payments for complementary and alternative medicine therapies cross-sectional study was restricted to adults aged 25 years or older. MEPS participants were asked whether they had consulted a provider of the following types of complementary and alternative therapies: acupuncture, nutritional advice, massage, herbal, biofeedback, meditation, homeopathy, spiritual healing, hypnosis, traditional medicine or other, for health reasons during the previous calendar year. If the response was ‘‘yes’’, the participant was asked to specify which of the treatments had been received. Use of multiple CAM therapies was possible. In MEPS, chiropractic was not included in the questions relating to CAM therapies but was treated as a form of conventional medicine. Therefore, as it could not be evaluated, it was not included in the analysis. Individuals who used only one CAM therapy in 1996 were then selected. Basic demographics, types of provider-based CAM therapies used, estimated number of visits to CAM providers and estimated amount of money spent for CAM were analyzed. The out-of-pocket calculations included only the following five CAM therapies used without other types: massage therapy, spiritual healing, herbal therapy, nutritional advice and acupuncture. The others were not considered because too few people were included in each of them (n < 15) and as the ‘‘other’’ category included many different types of CAM therapies. Reported out-of-pocket payments per visit, for each specific CAM therapy and for respondents whose CAM therapies were not covered by insurance, were constructed by dividing the amount paid for CAM providers by the number of visits to CAM providers, including only people who had no insurance or no insurance coverage for CAM. Population weights were applied to provide generalization to the US non-institutionalized civilian population. All statistical analyses were conducted using STATA 7.0.
49
Results Overall, 14,026 adults 25 years or older were included in the analysis. CAM was used at least once during 1996 by 6.1% (n = 836) of the sample, representing an estimated 11.2 million US non-institutionalized civilians. Of the 10 CAM therapies listed, the three most commonly used therapies were massage therapy (35%), herbal therapy (31%) and spiritual healing (25%). Out of the 836 users of CAM, 577 (69%) used only a single CAM therapy. Massage therapy (23.7%), spiritual healing (16.6%) and herbal therapy (14.7%) were also the three most frequently used CAM therapies among users of a single CAM therapy. Table 1 shows the mean amount of reported out-of-pocket money per visit paid for the five specific CAM therapies. The highest average amount of out-of-pocket money was paid for nutritional advice providers. Acupuncture, massage and herbal therapies providers came next, and last were spiritual healing providers with $9 paid per visit, on average.
Discussion The reported mean out-of-pocket payments per visit for CAM providers was $49 for nutritional advice, $44 for acupuncture, $33 for massage, $23 for herbal therapies, and $9 for spiritual healing. Reasons cited in the literature, for the trend toward the use of alternative therapies include a preference for a more holistic, integrative form of medicine, and a desire to use less technical and costly as well as more natural treatments, perceived as having fewer side effects.10—15 Dissatisfaction with conventional care, thought to be one reason for seeking alternative care, has been shown not to be a predictor of CAM use.4,16 Even
Table 1 Average reported out-of-pocketa money paid for CAM therapies.b Single used CAM therapies
Out-of-pocket money/visit paid for CAM providers: mean (S.D.), minimum—maximum
Nutritional advice (n = 83) Acupuncture (n = 33) Massage (n = 169) Herbal (n = 99) Spiritual healing (n = 125)
$49 (75), 0—450 $44 (38), 0—133 $33 (22), 0—140 $23 (49), 0—240 $9 (91), 0—1000
a
Out-of-pocket expenditure (rounded to the closest integer) = mean amount paid/mean number of visits, for a specific CAM therapy. b Respondents only included if their use of complementary and alternative therapy was not covered by insurance.
50 though spiritual healing is the second most used single therapy patients did not pay a great deal for it, although some patients paid up to $1000 for it. Herbal therapies and nutritional advice are two of the most frequently used and paid for CAM therapies. Because the majority of patients do not discuss their use of alternative therapies with their conventional care provider1,2,5 and as complications might occur after the use of herbs17 and nutritional supplements18 it seems necessary to be aware of the high use of these two therapies. The results of this study have two main limitations. First, there is no consensus on which therapies to include in CAM, defined many years ago as ‘‘medical interventions not taught widely at US medical schools or not generally available at US hospitals’’.1 As the MEPS list does not include chiropractic care as part of CAM, one widely used CAM therapy was not considered in our results. Second, these results excluded individuals using multiple CAM therapies. Therefore, they probably underestimate the reported amount paid out-of-pocket for CAM therapies, and generalization to all CAM users is not possible. CAM therapies have a substantial presence in industrialized countries, and more and more calls for the integration of CAM into the health care system rather than for a separation from conventional care are appearing in the health care literature.19,20 CAM efficacy studies, as well as studies based on costs and utilization data are necessary to help integrate the right care in the health care system, whether it is conventional or not. In this context, and because these are the first estimates of the average reported out-of-pocket payments people paid for specific CAM therapies, representing the importance people place on these therapies, the results of this study should be of value for health and public health professionals.
I.P. Bridevaux
3. 4. 5. 6. 7. 8.
9. 10. 11. 12. 13. 14. 15.
16.
17. 18.
References 1. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med 1993;328:246—52. 2. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990—1997.
19. 20.
Results of a follow-up national survey. J Am Med Assoc 1998;280:1569—75. Paramore LC. Use of alternative therapies: estimates from the 1994 Robert Wood Johnson Foundation National Access to Care survey. J Pain Symptom Manage 1997;13:83—9. Astin JA. Why patients use alternative medicine. Results of a national survey. J Am Med Assoc 1998;279:1548—53. Druss BG, Rosenheck RA. Association between use of conventional therapies and conventional medical services. J Am Med Assoc 1999;282:651—6. Wolsko P, Ware L, Kutner J, et al. Alternative/ complementary medicine: wider usage than generally appreciated. J Altern Complement Med 2000;6:321—6. Bausell RB, Lee WL, Berman BM. Demographic and health-related correlates of visits to complementary and alternative medical providers. Med Care 2001;39:190—6. Ni H, Simile C, Hardy AM. Utilization of complementary and alternative medicine by United States adults. Results from the 1999 National Health Interview Survey. Med Care 2002;40:353—8. Thomas KJ, Nicholl JP, Coleman P. Use and expenditure on complementary medicine in England: a population based survey. Complement Ther Med 2001;9:2—11. Furnham A, Bhagrath R. A comparison of health beliefs and behaviours of clients of orthodox and complementary medicine. Br J Clin Psychiatry 1993;32:237—46. Furnham A, Smith C. Choosing alternative medicine: a comparison of the beliefs of patients visiting a general practitioner and a homeopath. Soc Sci Med 1998;26:685—9. Furnham A, Forey J. The attitudes, behaviours and beliefs of patients of conventional vs. complementary (alternative) medicine. J Clin Psychol 1994;50:458—69. Kaptchuk TJ, Eisenberg DM. The persuasive appeal of alternative medicine. Ann Intern Med 1998;129:1061—5. Vincent C, Furnham A. Why do patients turn to complementary medicine? An empirical study. Br J Clin Psychol 1996;35:37—48. Vincent C, Furnham A, Willsmore M. The perceived efficacy of complementary and orthodox medicine in complementary and general practice patients. Health Educ Res 1995;10:395—405. Eisenberg DM, Kessler RC, Van Rompay MI, et al. Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey. Ann Intern Med 2001;135:344—51. Ernst E. Harmless herbs? A review of the recent literature. Am J Med 1998;104:170—8. McGuire JK, Kulkarni MS, Baden HP. Fatal hypermagnesemia in a child treated with megavitamin/megamineral therapy. Pediatrics 2000;105:E18. Dalen EJ. ‘‘Conventional’’ and ‘‘unconventional’’ medicine. Can they be integrated? Arch Intern Med 1998;158:2179—81. Davidoff F. Weighting the alternatives: lessons from the paradoxes of alternative medicine. Ann Intern Med 1998;129:1068—70.