RAA Directors (Chris Issel and Laura Aho) have been our contact and  reporting on CAM meetings as they  represent reflexology to the White House, the National Institiue of Health and the National Center for Complementary and ALternative Medicine since 2001.

HEALTH FORUM/AHA 2000-2001
COMPLEMENTARY AND ALTERNATIVE MEDICINE SURVEY
Sita Ananth, MHAProject Director, CAM

Introduction
Complementary and alternative medicine (CAM) has historically been associated with unconventional therapies that are not taught widely at U.S. medical schools or generally available in US hospitals. 1 However, this definition is quickly losing relevance. With 15% of hospitals stating they offer CAM therapies 2 and almost 60% of medical schools offering courses in CAM 3 , the lines between conventional or allopathic medicine and alternative therapies are growing fuzzier.
Increased consumer demand for CAM has created a powerful incentive for hospitals to expand their services. The landmark Harvard study, "Unconventional medicine in the United States - prevalence, costs and patterns of use" 1 together with the more recent update published in the Journal of the American Medical Association in 1997 4 , reveal the startling statistic that 42% of adults in the United States utilize one of sixteen forms of alternative therapies surveyed. Total out-of-pocket expenditures related to alternative therapies (professional visits, supplements, etc.) are conservatively estimated at $34 billion. This is comparable to all out-of-pocket expenditures for physician visits and exceeds out-of-pocket expenditures for all hospitalizations.
The above data is of great interest to hospitals, which are now responding swiftly to the needs of their patients while attempting to differentiate themselves in the marketplace and serve their organizational mission to improve the health of the communities they serve. In this study, we attempt to ascertain the prevalence and characteristics of hospital-based CAM programs in the United States.

Design and Methods
Phase 1
Each year the American Hospital Association's (AHA) Survey of Hospitals is mailed to all hospitals, both AHA-registered and non-registered, in the United States and its associated areas (American Samoa, Guam, the Marshall Islands, Puerto Rico and the Virgin Islands). The survey is mailed to the chief executive officer of the hospital. In the smaller hospitals, the chief executive tends to complete the survey. In larger hospitals, the survey is most likely forwarded to several offices to complete individual sections. In 1998, the AHA Annual Survey began to collect information regarding the existence of complementary and alternative (CAM) services, and if so, whether their CAM service is: provided by the hospital, health system or by a network formal contractual arrangement or joint venture. The definition for complementary medicine services used for Annual Survey purposes is: "Organized hospital services or formal arrangements to providers that provide care or treatment not based solely on traditional western allopathic medical teachings as instructed in most medical schools. Includes any of the following: acupuncture, chiropractic, homeopathy, osteopathy, diet and lifestyle changes, herbal medicine, massage therapy,refleoxlogy, etc." This question was used to screen for hospitals for Phase2 of the study. Specifically only those hospitals that reported a hospital-based CAM service were eligible for Phase 2 of the study. Hospitals that reported the service as being provided through their system or network or through a formal contractual arrangement or a joint venture with another provider were not eligible for the next phase of the study.

Phase 2
During this phase, a 10-item survey instrument was developed. This survey was designed to assess the specific characteristics of the programs that were identified in Phase 1. Specifically the Phase 2 survey questions included: which CAM therapies were offered and whether they were offered on an inpatient or outpatient basis; reimbursement and payment methods; organizational motivation for offering these services; obstacles and challenges to implementation; and resources used by the organization or individuals to access CAM information. This survey was mailed to all hospitals that responded affirmatively to the 1999 AHA annual survey question as defined above. Phase 2 surveys were distributed in two mailings in 2000 and 2001. The initial mailing occurred in November 2000 with a follow-up mailing occurring in the following year.

Results
Prevalence
In Phase 1, 5,810 hospitals were surveyed through the AHA Annual Survey with approximately 84% responding the survey. Of these, 502 or slightly over 23% responded positively to offering hospital based CAM services. For Phase 2, there were 158 respondents for a response rate of 31%.

Geographical Distribution
Of the 502 hospitals who responded in Phase 1, the highest percentages of CAM activity by region were in the East North Central (Illinois, Indiana, Michigan, Ohio, Wisconsin) 25%; Mid-Atlantic (New Jersey, New York, Pennsylvania) 18%; and West North Central (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota) 14%. Of the 158 respondents in Phase 2, the response proportions by region were comparable to the regional distribution of the entire CAM population as defined in Phase I by the Annual Survey. There were some exceptions. The South Atlantic region (Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia) had the second highest percentage of respondents at 16% compared with only the fourth highest percentage of respondents in the overall population. The percentage of respondents in the Mountain region (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming) 11% was more than twice higher than its representation in the general population (5%).

Other Hospital Characteristics
The entire CAM population is heavily urban as compared to rural, 76% to 24% respectively. The 158 Phase II respondents generally mirror these proportions although the response set is slightly less urban and slightly more rural at 70% and 30 % respectively. However, the differences between the entire population and the set of respondents are not significant.
Likewise the response set generally mirrors the entire population broken-down by hospital size category. For purposes of this analysis, small, medium, and large hospital size categories were created. The small category was defined as fewer than 100 beds, the medium category consisted of between 100 to 399 beds and the large category had 400 beds or more. In both the entire population and the response set, the majority of all programs were found in the medium size category. However, the percentage of respondents in this category was less than in the general population at 55% to 51%.
While there was virtually no difference in the small category, the large category was slightly over represented in the response set as compared to the general population at 28% to 23% respectively. While the differences noted above are interesting observations, none of them are considered to be significant.

Services offered
The Phase 2 survey requested information on the current availability of each of 16 services and whether offered in an inpatient and/or outpatient mode. The sixteen services are: Acupressure, Acupuncture, Aromatherapy, Biofeedback, Chiropractic, Guided Imagery, Herbal Medicine, Homeopathy, Message Therapy, Medical Symptom Reduction Program, Naturopathy, Pastoral Counseling/Spiritual Care, Reflexology, Relaxation Treatment/Training, Therapeutic Nutrition, Therapeutic Touch. The five most popular services after combining both inpatient and outpatient occurrences are Pastoral Care (197), Massage Therapy (159), Relaxation Treatment (133), Guided Imagery (107) and Therapeutic Nutrition (103). No other service had a frequency of 100 or more. The five least frequently reported services after combining both inpatient and outpatient occurrences are Naturopathy (8), Homeopathy (13), Chiropractic (19), Medical Symptom Reduction Program (20), Reflexology (36). The remaining six services ranged from a frequency of 38 (Herbal Medicine) to 97 (Biofeedback). On average, a service was much more likely to be provided in an outpatient setting (66%) than an inpatient one (34%). In fact, inpatient provided Pastoral Care was the only instance where the inpatient service was predominate at 55%. In the remaining 15 service instances there were more outpatient occurrences of a service and in many cases the differences were very significant. In these 15 instances, the outpatient percentages ranged from a high of 90% for Chiropractic to a low of 54% for Therapeutic Touch. Other than Pastoral Care, there were only four services with an inpatient occurrence rate of greater than forty percent. These services and their inpatient percentage are Therapeutic Touch (46%), Guided Imagery (42%), Relaxation Treatment (42%), and Therapeutic Nutrition (41%).

Research - Ongoing research projects funded by NIH/National Center for Complementary and Alternative Medicine will help to validate the clinical efficacy of CAM therapies. Hospitals tend to offer services with clinical effectiveness and safety ; that are demanded by their constituents; or therapies for which they have internal expertise. As the research base becomes stronger, it is likely to increase the number and types of CAM services offered.

Education - More than 70% of patients withhold information about their CAM use from their physicians. 6 When this happens, potentially dangerous consequences such as drug -herb interactions can result. Whether hospitals decide to offer CAM services or not, it is critical that clinicians are trained not only in how to elicit this information but also to know more about the therapies their patients are using. Although many formal educational programs for medical students are providing content about some therapies, that content is not consistent and is often offered in elective courses, rather than being integrated into required ones.7,8 Reimbursement - The study findings reveal that the majority of CAM services in hospitals are offered on an outpatient fee-for-service basis. This has created an unfortunate chasm in access leaving CAM available primarily to the insured or those with disposable income. One strategy to provide more CAM services, while facilitating their easier acceptance is to integrate them into existing programs such as pain management, oncology, etc. This has the added benefit of making CAM therapies easier to include and more difficult to remove when financial cuts eliminate separate programs. Additionally, education of legislators, policy makers and business leaders is crucial for these services to be valued and reimbursed.

9 Credentialing - The four most commonly used CAM therapies- acupuncture, chiropractic, naturopathy and massage therapy - offer standardized national exams for their professions and are licensed in most states. However, many hospital administrators are unclear on the process of credentialing CAM providers, particularly if they are not licensed in their state. Hospital administrators need to educate themselves so that they can begin to credential these providers. Most CAM therapies have educational, experiential, or approval requirements for their practice and often have a national or international organization that can be helpful.

Limitations
Although the number of Phase 2 respondents is somewhat low, the high degree of correlation between the characteristics of the entire population and the Phase 2 response set would suggest that the results are reasonably reliable and certainly representative of the entire population. We will continue, though ongoing surveys, to improve the accuracy of these results and to continue to track CAM activities in hospitals. Results from this study will be used in a variety of ways by Health Forum and AHA to encourage and support hospitals with their educational, resource and networking needs as they enter into this arena.

In conclusion, the study results have revealed a wide and varied array of approaches to
CAM in hospitals - from free-standing CAM clinics offering a range of CAM therapies on an outpatient basis to integrative, patient-focused, comprehensive care on both inpatient and outpatient basis. For example, Catholic Health Initiatives' view of integrative care as comprehensive, collaborative and personalized to meet each patient's need rather than therapy-centered 10 is one model that allows for this to happen. For true integration to occur, CAM has to be brought in from its "quarantine" 11 and the best of what CAM has to offer will become an integral part of our healthcare.

For more information, contact Sita Ananth at sananth@healthforum.com or at 707/644-1181.

References

1. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. New England Journal of Medicine 1993; 328(4): 246-252
2. American Hospital Association Survey of Hospitals, 2000
3. Carlston M, Stuart M, Jonas W. Alternative Medicine instruction in medical schools and family practice residency programs. Family Medicine 1997; 29:552- 62
4. Eisenberg DM, Davis R, Ettner S, et al. Trends in alternative medicine use in the United States 1990-1997; Results of a follow-up national survey. JAMA 1998; 280(18): 1569-1575
5. Eisenberg D. Advising patients who seek alternative medical therapies. Annals of Internal Medicine 1997; 127:61-69
6. Gaudet T, Sierpina V, Lee R, Greenfield R. The changing face of medical education. Alternative Therapies in Health and Medicine Annual Symposium, New York, March 1999
7. Wetzel MS, Eisenberg DM, Kaptchuk TL. Courses involving complementary and alternative medicine at US medical schools. JAMA 1998; 280(9): 784-787
8. Milton, Doris Complementary therapies: Reimbursement Issues. In Mason, DJ, et al. (Eds.) Policy and Politics in Nursing and Health Care. 4th Ed. Philadelphia, Saunders, 2002.
9. Middleton, Carl. Integrative Health Care: An Emerging Approach to the Art of Healing. Denver: Catholic Health Initiatives 2001.
10. Weeks, John. Alternative Medicine moves in with Conventional Medicine. Healthcare Forum Journal 1998 November/December; 14-19

Article taken from Reflexology Association of America’s Newsletter

Summer 2003, Volume 8, Issue 4

Written by Laura Aho Jodry – President of RAA

Last month I received an invitation to attend a meeting facilitated by the American Massage Therapy Association's Massachusetts Chapter (AMTA-MA). The invitations were sent out to area schools and wellness centers along with a few bodywork organizations. The AMT A is once again attempting to go for a licensing law in Massachusetts for massage therapists.

Many of you have had the opportunity to work with -or even against -your state massage associations. And as with those dealings, this issue in Massachusetts will assuredly follow a similar track. You know the path; massage attempts to collect as many body therapies as possible under its umbrella to increase their numbers on paper, which in turn can help them get their bill passed. So here we go in Massachusetts again as has happened in many states allover the country. Time to fight the big fight, standing up for Reflexology's autonomy.

I contacted the folks in the newly formed Massachusetts Association of Reflexology to tell them the news and offered to submit a Reflexology position paper at the meeting. The position paper was decided with the help of the RAA Legislative Committee. Basically it states Reflexology's wish for a formal written exemption in the Bill's wording and once that is written into the Bill, reflexologists will be happy to assist the massage profession of Massachusetts toward its goal of licensure.

Two weeks later I found myself at this first coalition AMT A-MA meeting with a Reflexology position paper tucked neatly into my notebook just waiting for the opportune moment to present. Listening carefully to the professional lobbyist while she explained how the Massachusetts legislature works, I remember thinking I was getting a great free education into legislation and being thankful to the AMT A-MA for the opportunity. Once her presentation was complete, she opened the floor to a bit of Q & A.

Folks did have some basic questions about the coalition and how its run, but soon questions turned into comments, no...actually, declarations. For instance, a representative from the Trager field was quick to present a formal verbal statement that Trager wants no part in this bill and desires exclusion. Aha! Someone had opened the door and the opportune moment for the position paper had arrived. I then raised my hand and introduced myself to the lobbyist and the AMT A Laws Committee stating Reflexology's desire for formal written exemption and presenting the position paper.

I explained that Reflexology is simply requesting that the Massachusetts branch of the AMT A follow the guidelines set forth by the national AMTA's Government Relations Committee, which recommends that states make a formal exclusion for Reflexology when introducing or changing an] massage bill.

Well, things got interesting after other disciplines offered similar positions, though verbally -not Formally -written. Out poured questions from Trager reps, Alexander Technique reps, Asian Bodywork organizations, and even the American

Massage and Bodywork Profession group. Strangely, the questions were not directed toward the AMTA or the lobbyist -they were directed at the Reflexology community. Folks were truly interested in hearing the thoughts, opinions and position of Reflexology on this Bill. The reflexologists in attendance at this meeting were myself, Val Voner and Jack Roso (both RAA members, Reflexology school owners and practitioners).

After we answered some direct questions regarding our position on this issue, I politely transferred the queries toward the massage group and the lobbyist. The meeting then went on and the AMTA said they have not started revising the wording and that anyone interested in insuring the wording works for their modality is invited to join the coalition. Ah yes, politics. So here we go in Massachusetts.

After the meeting, I was sure to sign on to the coalition and to express my desire to help the AMTA and insure Reflexology's role (exemption) in the process. The committee seemed, well...let's say somewhat re-signed to my offer rather than pleased. OK, I thought- this day down and however many more to go. So I gathered my things and started for the door. Now I thought the day had been full of surprises thus far, but incredibly there were more to come.

I was approached by the Trager Reps, the AMBP, Alexander reps and the Asian body work reps, all wanting to know how Reflexology does it, what it has in place and if they can use our professional organization as a model. They wanted information on how to form state associations and develop watch-dog techniques toward the massage industry. Other folks wanted to know where they could train in Reflexology as they'd heard of its efficacy. Everyone I spoke with knew Reflexology was not massage.

So I talked for while, answered more questions and set up a few connections before heading back to work and the comfort and serenity of working on clients. At the end of my working day, I thought about the events from the meeting and was heartened at the sizable impact Reflexology's presence had made during and after the meeting. I felt proud to be part of a discipline that is admired by others and felt comforted in the knowledge that the Reflexology community is respected by many of its peer groups.

Other disciplines see Reflexology as a profession -Imagine? -one that has all its "ducks in a row" and they wish to actually be where we are in the overall scheme of things. What an eye opener! Sometimes you have to look in from the outside, in this case through the eyes of other disciplines, in order to see all that there is to see. Reflexology looks

good from out there. And I wanted to pass this positive experience on to you. It is my hope that you realize we are respected and admired. The effort through the years made on behalf of Reflexology, by reflexologists, is astounding. We do have our "ducks in a row". We have a national certification board and accreditation board. We have state associations and of course, RAA. We gather as a community behind issues that affect our field. We work as individuals, but we also work as a community. We are professional and Reflexology is worthy of the praise I heard it given that day.

Though we sometimes feel it's a never- ending battle (up hill; in the snow -without shoes) toward a true profession, it is good to remember that Reflexology has come a long way from where it began. Everyone involved, whether practitioner, teacher, client, board member, or volunteer, has had a hand in creating this beautiful picture. So take a moment and sit back -forget for a second where we are going -and look at where we are! Admire yourself as well as the beauty of our community. Continue the climb toward the future, but along the way, stop to look back over the panorama behind you. Look at all you've done. Look at all we've done!

Be content that reflexology does not have all the answers yet, but be inspired by your passion to find them. Be proud in its existence. Nurture Reflexology as it is now. Don't wait for its approval as a profession to come in the form of clinical trials noting its efficacy, or from a state approving licensure, or from insurance company acceptance, or from anything else. The connection, the validation, the growth of our profession and ourselves comes from our individual and collective

spirit. Let that be your inspiration and your energy source. Use that energy to continue building a strong foundation for Reflexology. We've built our castle in the clouds. That's ok; that's where it should be. Now let's put a foundation under it!

Laura Aho Jodry