Vermont Bill S.209 - Craig Jones, MD

Vermont House Health Care Committee 

Hearing On Bill S.209

April 11, 2012

Craig Jones, MD

Dr. Jones’s testimony is recorded on a CD which can be purchased for $1 from the Legislative Council, tel. 802-828-2231. It is CD # 164, House Committee On Health Care, Wednesday, April 11, 2012.

This is my report on what Jones, the Director of the Vermont Blueprint for Health, http://healthvermont.gov/admin/legislature/documents/blueprint_leg_report.pdf, told the committee.

Jones believes it is important to include NDs, naturopaths, in the Blueprint because they are already practicing as PCPs, primary care physicians, in Vermont and aside from Medicare are already reimbursed by insurers for the services they provide in that capacity. Once included, NDs will be scored like “tradition medical practices” are against the “fairly rigorous” Medical Home national  standards set by NCQA, http://www.ncqa.org/, National Committee for Quality Assurance. This will in turn help to evaluate the quality of health care offered to all Vermonters seeing all PCPs, not just MDs.

According to Jones, the services of NCQA are used by many states to evaluate how well medical practices: comply with guidelines for basic care; provide access to doctors; communicate with patients; coordinate with team members like social workers; and, whether or not their outcomes are tracked electronically. Because of that, Jones believes that including NDs in the system will: guarantee the quality of the services they provide; and, give their patients access to the other team members like dietitians, social workers and counselors. 

Jones pointed out that since NDs are already practicing in the system, scoring them according to the same standards by which MDs are scored and giving them access to the other professionals MDs have access to would only improve the situation and the quality of care provided which is in line with the intention of the Blueprint that aims to improve the quality of care and to coordinate the services provided to Vermonters.

Jones said that he had had discussions with NCQA and found that they would be willing to receive and score data collected from VT ND practices and report the scores to the state. He added that NCQA now recognizes and scores nurse practitioners, NPs, and physicians assistants, PAs, as primary care provides, although it did not do so a few years ago. 

According to Jones, NCQA did an exhaustive review of how each state regulates naturopaths and found that out of the 50 only 16 have any laws pertaining to them. Among those 16, there is no consistency, no national standards or protocols for NDs that apply broadly across states as there are for MDs, NPs and PAs. For that reason NCQA couldn’t give their “stamp of approval” to NDs because although NCQA is not a licensing body, it wants its stamp of approval accepted by all the states. 

In a compromise Jones worked out with NCQA, the agency agreed to score VT NDs using the same standards used for all practitioners in the system and report their scores to state officials. They would not, however, include NDs as a profession officially recognized by NCQA on their website. 

Bill S.209 would, Jones said, take something already included in the health care system, NDs practicing as PCPs, and add it to the Blueprint/Medical Home thereby making the Blueprint more “holistic” while assuring the quality of the additional services by measuring them against objective standards. 

Under the Blueprint, teams from UVM, University of Vermont, medical school go into practices and score them against NCQA’s national standards. The way they do that will be the same for NDs as it is for MDs. The UVM team sends the documents and support material it gathers during its reviews to NCQA in Washington, DC where they are tested against national standards. Then the scores are sent to VT officials. But under the compromise Jones worked out, with NDs, unlike others, the final step of stating on the official NCQA website that the practice is an NCQA officially recognized Medical Home will be omitted.  

The Blueprint has teams of facilitators that work with practices for 4 - 6 months to teach them how the system works. The same teams that work with MDs will also work with NDs.

Jones repeated again that including NDs in the plan would make an “existing situation stronger”. He believed that VT is setting the standards for including NDs in Medical Homes across the nation. 

The Blueprint director concluded by saying that it is his personal belief that MDs wrongly frame the question as “us versus them” when the entire point of the Blueprint is to provide more holistic care offering “complete services” for the general public. In his opinion the “hurdle” is cultural.

Comment:

I am in the process of attempting to verify the claims Jones made about NCQA, its agreement with VT and its accreditation procedures and may have more to report on that later.

When I heard Dr. Jones speak, I found him very persuasive. Listening to him for the first time on the CD, I thought that he was correct. If all those practicing as PCPs are evaluated by the same yardstick, the public’s interest is served. However, as I thought more about the doctor’s talk I changed my mind. I saw some very serious hurdles that are not cultural. They are factual. It appears to me that Jones’s conclusions are based on assumptions and the unverified, self-serving claims that naturopaths make about themselves.

1. Jones said repeatedly that Vermonters are already being treated by NDs. Really? Where’s the evidence, Doc?

Looking over the material presented to the committee, I noticed a handout submitted by Lorilee Schoenbeck, ND stating that somewhere over 5,000 Vermonters are using NDs as PCPs, the number of VT NDs practicing primary care is “40 and growing”. 82% of those are “credentialed” to be reimbursed by insurance and of those 95% are taking new patients. 7.4% of the PCPs in VT are NDs. http://rosemary-jacobs.blogspot.com/2012/05/vermont-bill-s209-lorilee-schoenbeck-nd.html.

But what does that mean? I don’t think we have all the statistics needed to know. 

According to the US census, http://quickfacts.census.gov/qfd/states/50000.html, the population of Vermont was estimated at 626,431 in 2011. If only about 5,000 of those people are using NDs as PCPs, in reality there are very few Vermonters already seeing them. I wonder what the reason for that is. But if Schoenbeck, who said in her oral testimony that many MDs are not taking any more primary care patients and that many who are have long waiting lists yet 95% of Vermont’s ND PCPs are looking for more patients, it would seem to me that few Vermonters want their services.

If you look at the members listed on the NDs official site, VANP, http://www.vanp.org/member_directory.php, you will note that several of those who practice in VT also practice in adjoining states like NY and MA where they cannot be licensed. And a few work out of more than one office in VT. 

If you investigate individual VANP members, you find that in addition to seeing patients most sell supplements, some do Skpye consultations, at least one teaches and one gives advice in a natural products store. You will also see that NDs claim that they spend a long time with each patient. One says an initial consultation takes 90 minutes and it seems as if repeat visits for most are at least 35 minutes.

Considering all that, it sure doesn’t sound to me as if a lot of Vermonters are using the services of NDs. In fact it doesn’t sound as if Vermonters want their services. It sounds as if NDs need more Vermont patients to stay in business, especially when you consider that according to the Director of the Office of Professional Regulators there are 241 of them licensed in Vermont. Presumably, they are either employed in other occupations or are residing and practicing naturopathy somewhere outside the state.

My guess is that it is the failure of most NDs to attract enough customers to stay in business practicing their profession that is the real reason that naturopaths are lobbying so hard to be granted all the same privileges that MDs have. Think about it. Even though Vermont licenses NDs as PCPs and insurance reimburses for their services, Vermont is reporting a shortage of PCPs yet 95% of the ND PCPs here are looking for more patients. That sounds to me as if Vermonters want more MD PCPs in the system, not more NDs.

This raises another question. With so few Vermonters using the services of NDs, why is it that the NDs have so much influence on the legislators and the state bureaucracy which is advocating for them? I have no evidence, but I believe that the billion $$$ dietary supplement industry is behind it because NDs promote, use and sell their products. 

Then there is the other side of the coin. 

In addition to NDs Vermonters “are already seeing” many other kinds of old hippy, New Age “health care practitioners”. Check out the rest of the practices that share the building with Lorilee Schoenbeck, http://www.easternviewvt.com/, by clicking on “the practices” button. 

According to Jones’s logic, we should let any of them who requests it practice in Vermont Medical Homes because they are already practicing here and people want to use their services. They probably want to have third party payers reimburse them too. Isn't everyone in Vermont who thinks he practices medicine entitled to be given what he wants or is it just a lucky few? Maybe we should give them all prescription privileges too like the legislators just gave to the NDs when they passed H.524. http://rosemary-jacobs.blogspot.com/2012/02/vermont-bill-h524-vt-nds-prescription.html.

I’d have a great deal more respect for libertarian politicians who say they voted for laws giving NDs the same privileges as MDs have in order to guarantee the public’s “freedom of choice” if they passed laws decriminalizing street drugs, legalizing assisted suicide and doing away with the requirement that a prescription is needed to buy legend drugs so that Americans, just like their Third World cousins, could buy whatever antibiotic, heart med, pain killer, etc. they wanted without having to convince a doctor that they needed it. If politicians did those things, I’d believe that “freedom of choice” and not political expediency motivated their actions.

2. Dr. Jones thinks that by including NDs in the Blueprint that their patients will have access to other professionals included in the team like dietitians, social workers and counselors. 

Does he know anything about naturopaths? They constantly insist that nutrition and counseling are included in their scope of practice. They claim that they practice “holistic” medicine and treat the “whole person”, his “mind, body and spirit”. They believe that they are shrinks, healers and preachers.

http://www.bastyr.edu/sites/default/files/images/pdfs/course-catalog/School_Naturopathic_Medicine_11-12.pdf (p. 70 & 74)

http://www.drhaff.com/Services.html

http://www.aanmc.org/naturopathic-medicine/nd-primary-care-provider.php

Does Jones really think they believe they need to refer patients to team members competing with them in what they believe are their areas of expertise? 

The team concept is a model traditionally used by MDs who refer patients to dietitians, physical therapists, psychologists, social workers, etc. The holistic concept is an alt. med. model in which the practitioner believes he can and should treat the patient’s entire or whole being, his mind, body and spirit.

3. Dr. Jones reports that NCQA discovered that NDs don’t have a national standard like MDs, NPs and PAs.

HELLO, LEGISLATORS! HELLO BUREAUCRATS! DID YOU HEAR THAT? Have you also heard and read the continuously repeated claim by NDs that they have to pass the USMLE, United States Medical Licensing Examination, and that it is a rigorous test the passing of which shows that they know as much as MDs do? IS THERE A FACT CHECKER IN THE HOUSE?

4. Jones tells us that those who do not meet the NCQA standards will not be permitted to practice. Really?

Based on my experience with the way Vermont has “regulated” NDs, I don’t believe it. The state let them write their own formulary in consultation with a pharmacologist. When the pharmacologist objected to the inclusion of IV substances, he was ignored, http://rosemary-jacobs.blogspot.com/2012/04/do-naturopaths-in-vermont-use-silver.html, # 6. They let 2 ND advisors write a test that those two and their colleagues took. Passing it gave them the right to use the drugs in the formulary that they had drawn up. It was a 48 hour test the person could take anywhere his heart desired. A person with no college science courses did just that and passed, http://vimeo.com/37305517. According to their rules, NDs were supposed to annually review and update their formulary. Between 1996 and 2012, they did that once. My complaints about their using dangerous snake oil and breaking federal drug laws have never been looked into. The state bureaucrats take whatever the NDs tell them at face value without independently verifying a word of it. 

All of that tells me that the State of Vermont is doing all it can to empower naturopaths to do whatever they want as long as they don’t get caught hurting anyone because that would make the state look bad, and if, as Jones stated, the official NCQA website will list all Medical Home practices that the agency has officially recognized, except those of NDs, there will be no way for the public to verify that they have met the agency’s standards. We will just have to take the state’s word or it.  

5. Jones and Schoenbeck think it will be wonderful to include NDs in the Blueprint so that they can have their practices evaluated.

Excuse me. I thought professions had to be evaluated before they were let in the door to see if they were qualified to perform the job. Has any other profession gotten through the door before it gathered the appropriate data to show that its members were capable of doing what they claimed they could? MDs have kept records for as long as I can remember and I’ll be 70 before the end of summer. Somehow I suspect that record keeping is a relatively new practice with NDs. It certainly is according to VANP’s rep, Lorilee Schoenbeck, who stated in her oral testimony that including them in the Blueprint is a good idea because it will let them capture data that will show whether or not their beliefs about the benefits of their “preventive” medicine are accurate. Schoenbeck’s statement is an admission that her profession hasn’t gathered the data needed to determine if their claims of safety and efficacy are correct, but that has never kept them from insisting that they are.

6. According to Jones, the Blueprint was intended to provide Vermonters with more “holistic” care. Really?

I thought the intention was to provide improved outcomes with lower costs.

7. Dr. Jones believes that MDs are framing this as “us versus them” when they shouldn't be. 

Wait a minute. Aren’t the naturopaths and their advocates doing that? Haven’t they been doing that ever since they entered the picture?

Hinda Miller said in her testimony, “There has always been tension between those of us who feel nutrition and diet and all those things can help us maintain our health…” and those other guys, the MDs, http://rosemary-jacobs.blogspot.com/2012/05/vermont-bill-s209-hinda-miller.html. She includes herself with NDs and considers MDs “them”. This attitude is a strong element running through all alternative medicine and has been there ever since the term was coined. It is usually accompanied by rants much stronger than Hinda’s about big, bad, medical doctors on the take and pharmaceutical companies conspiring to keep us all sick so that they can rake in the gold. I myself have repeatedly been falsely and viciously accused of being funded by “the medical establishment, the drug cartel” and the government too because alts don’t like what I say about silver and their belief-based systems of medicine and can’t comprehend that anyone not paid to do so would ever disagree with them. They are so certain that their beliefs and feelings are right and that those of us who base our conclusions on objective evidence that contradicts their beliefs and feelings are wrong.

Critics like Jones, Miller, et. al should be discussing the reasons why MDs who practice evidence-based medicine contend that NDs are not qualified to practice medicine safely and effectively and they should investigate to see if their allegations are correct rather than simply dismiss them out of hand. If in fact, NDs had the same education that MDs have, why would it disturb MDs that they were permitted to practice as PCPs too, especially given the fact that there is an acute shortage of such practitioners in the state? If their educations were the same, MDs would welcome NDs into the fold with open arms.

And the state bureaucrats should stop telling us how safely NDs practice as PCPs based on what they did yesterday which is different than what they are doing today or what they will be doing tomorrow. Till very recently naturopaths practiced as “drugless healers”, not PCPs. Even now most states refuse to license them.

There is no way to draw conclusions based on the number of complaints filed against NDs unless you know how many people they’ve treated, what they treated them for, whether or not those people were sick, hypochondriacs or the worried well who the NDs simply gave diet and exercise advice to. You also have to know things like whether or not their patients were being treated by MDs or other practitioners at the same time, practitioners who maybe told them not to drink the silver or take the botanical because it might poison them or interfere with their heart medication. 

Even with such information, the statistics wouldn’t take into account the harm and premature deaths that don’t show up for years and which may never be associated with the “remedies” or practitioners who caused them. That is a lesson those who practice scientific medicine learned years ago and is why they strive to throughly test their drugs and therapies for safety and efficacy before they use them.. Remember thalidomide? NDs sure don’t. http://guides.main.library.emory.edu/content.php?pid=156723&sid=1327606, http://pubs.acs.org/cen/coverstory/83/8325/8325thalidomide.html. 

Naturopaths with their untested “natural medicine” bring us right back to where we were when thalidomide deformed so many innocent children. They are creating a two tiered system of medicine, one with rigid standards, the other with virtually no standards, but worse yet, they are blurring the line between the two so that patients can’t tell one from the other.

The vast majority of people injured by unscientific or alternative medicine never complain or sue. Many never realize that their health problems could have been caused by a “natural remedy” and most of those who do are too embarrassed to say anything. They feel like fools when they realize that all the alt BS they believed about how horrible evidence-based medicine and its practitioners are and how good the alternative kind and its practitioners are is bunk. I know this all too well from dealing for years with silver victims. And to date, the vast majority of people attracted to alts have been the most gullible and sometimes the most desperate among us, but thanks to the lobbying efforts of naturopaths, many less gullible people will use their services tricked into believing that they offer the same evidence-based medicine as MDs do because the state implies it by giving them all the same privileges. 

As for the unseen harm they do, consider the fact that alts, including NDs, have traditionally opposed vaccinations. Most still do. Vaccination rates are lower in the areas where there are a lot of alts. So let’s say you live in one of those areas. Vaccination rates are down. Your infant is too young to be vaccinated against whooping cough, contracts the disease and dies. Do you sue the naturopath down the road who convinced your neighbors not to vaccinate their children?

Craig Jones; Vermont Blueprint for Health; NCQA; VANP; naturopaths; Vermont Bill S.209; Vermont House Health Care Committee